A History of Aeromedical Evacuation

in the U.S. Air Force

Dr. Thomas A. Julian

Air Force History and Museums Program

United States Air Force

Washington, D.C., 2015

i

Preface
Library of Congress Cataloging-in-Publication Data

Julian, Thomas A., 1930-

A History of Aeromedical Evacuation in the U.S. Air Force / Thomas A.

Julian

XX p.  XX cm.

Includes bibliographical references and index.

1. United States. Air Force—Officers. 2. United States. Air Force—

Personnel management—History. 3. United States—History, Military—20th

century. I. Title. 

UG793.M582001

358.4133'0973'dc20 00-19357

For sale by the U.S. Government Printing Office

Superintendent of Documents, Mail Stop: SSOP, Washington, DC 204002-9328

ISBN 01-166-XXXXXX-X

ii
A History of Aeromedical Evacuation

in the U.S. Air Force

iii
iv
Contents

1. The History of Aeromedical Evacuation in the . . . . . . . . . . . . . . . . . 1

United States Air Force

2. David Grant and the Emergence of Organized Aeromedical . . . . . . . 31

Evacuation in the United States Army

3. Aeromedical Evacuation and the Logistic and Tactical . . . . . . . . . . . 53

Requirements of Global War

4. The Postwar Evolution of Aeromedical Evacuation . . . . . . . . . . . . . . 81

5. The Korean War and the Emergence of the Modern . . . . . . . . . . . . . 103

Aeromedical Evacuation System

6. The Modern Aeromedical Evacuation System Emerges . . . . . . . . . . 125

from the War in Vietnam

7. Modernization, Centralization, and New Aeromedical . . . . . . . . . . . . 153

Evacuation Paradigms

8. Aeromedical Evacuation in the New Era of Jointness . . . . . . . . . . . . 177

9. The Persian Gulf War: Test of the Total Force . . . . . . . . . . . . . . . . . . 193

10. Emergence of the Post–Gulf War Aeromedical Evacuation . . . . . . . . 233

System: Trends, Issues, and Bureaucracy

11. Emergence of the Post–Gulf Aeromedical Evacuation . . . . . . . . . . . . 257

System: New Contingencies

12. Epilogue: Emerging Critical Issues for Reengineering . . . . . . . . . . . 287

the Aeromedical Evacuation System

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439

Photographs

Dr. Harry Armstrong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

A Breguet 14A.2 aircraft, of the type configured as an air ambulance . . . . . . . . .12

v
Lt. Col. Theodore C. Lyster, father of aviation medicine . . . . . . . . . . . . . . . . .14

Curtiss JN–4D, a training plane modified to accomodate patients, circa 1918 . . . .17

Douglas C–1, Air Service aircraft modified to accomodate patients . . . . . . . .24

Fokker T–2, Air Service aircraft modified to accomodate patients . . . . . . . . .25

DH–9 Air Ambulance with Z Force in British Somaliland, 1919 . . . . . . . . . .29

The Cox-Klemin aircraft, designed for and dedicated to aeromedical evacuation 33

Maj. Gen. James G. Harbord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Maj. Gen. David N. Grant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

C–47s were used to evacuate the wounded . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Ground transportation took the wounded from the C–47 air ambulance . . . .55

C–47 air ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

C–54 aeromedical evacuation aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Interior furnishings of a C–54 air ambulance . . . . . . . . . . . . . . . . . . . . . . . . .58

B–29 bombers, main bombing aircraft used against the Japanese homeland . . . .82

Immediately after the atomic bomb drop on Hiroshima . . . . . . . . . . . . . . . . .85

Maj. Gen. Malcom C. Grow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

C–54s were commonly used for aeromedical evacuation from Korea . . . . .106

Casualties being transferred from an H–19 to a C–54 . . . . . . . . . . . . . . . . .107

The Sikorsky H–5 was often used to carry casualties in Korea . . . . . . . . . . . . . .112

The H–19 was often used to ferry wounded soldiers . . . . . . . . . . . . . . . . . .116

The Douglas C–118 Liftmaster outfitted for aeromedical evacuation duties . . .128

The Convair C–131 Samaritan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129

UH–1 Huey evacuating casualties in Vietnam . . . . . . . . . . . . . . . . . . . . . . .138

Col. Regina Aune, heroine of Operation Babylift . . . . . . . . . . . . . . . . . . . . .154

Orphaned children being loaded in Operation Babylift . . . . . . . . . . . . . . . .155

Exultant ex-POWs ready for take-off as free men again . . . . . . . . . . . . . . . .158

Freed POWs line up to board their return aircraft at Clark Air Base . . . . . .159

C–9 Nightingale aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162

The aftermath of the bombing of the Marine Barracks in Beirut, 1983 . . . .176

The AC–130 gunship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179

The F–117 Nighthawk stealth fighter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180

Howard Air Base, Panama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182

Marines on patrol during Operation Just Cause . . . . . . . . . . . . . . . . . . . . . .184

A wounded soldier being evacuated from the battle during Desert Storm . .197

20th SOS rescues Navy Lt. Devon Jones during Operation Desert Storm . . . . .198

Marines evacuating casualties on a C–141 in February, 1991 . . . . . . . . . . .226

Operation Provide Comfort in 1991 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .228

A Kurdish refugee camp in 1991 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229

C–141 on the ramp at Mogadishu, during Operation Restore Hope in 1992 . . . .258

Marines patrol Mogadishu, during Operation Restore Hope in 1992 . . . . . .259

USAF workers unload bags of flour during Operation Restore Hope . . . . .266

Casualties being evacuated from a downed Blackhawk in October, 1993 . .276

vi
Maps and Illustrations

Human factors in aircraft design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

Map of the Korean Peninsula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104

Map of Southeast Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150

Map of Southwest Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195

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A History of Aeromedical Evacuation

in the U.S. Air Force

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Chapter 1

THE HISTORY OF AEROMEDICAL

EVACUATION IN

THE UNITED STATES AIR FORCE

In his memoir of World War II, Crusade in Europe, Gen. Dwight D.

Eisenhower, Supreme Allied Commander in Europe, commented on the efficiency of the medical service of the U.S. Army. He noted that the fatality rate among

those wounded was less than half that reported for World War I. While citing

many reasons for this reduction in fatalities he singled out “penicillin and the sulfa

drugs, early use of blood plasma, and an efficient system of evacuation, a great

deal of it by air.”1

Indeed, a great deal of this success can be attributed to air evacuation. In

Eisenhower’s European theater of operations (ETO), 82,000 patients were

brought out by air from east of the Rhine River in the peak month of April 1945.

The Army Air Forces (AAF) in all theaters had evacuated more than 1,172,000

sick and wounded patients during the 27-month period, January 1943 through

May 1945.2

Eisenhower’s comment at a press conference in June 1945 that “we evacuated almost everyone from our forward hospitals by air, and it has unquestionably

saved hundreds of lives—thousands of lives,”3 also applied to theaters worldwide

where U.S. forces had been engaged, certainly not least in the southwest Pacific,

where evacuation of wounded and sick by air had been both a medical and logistic necessity.

Aeromedical evacuation—the movement of wounded and sick military men

and women by aircraft—is a twentieth-century phenomenon in spite of the romantic and widely repeated story of sick and wounded Parisians being evacuated from

the besieged city by balloon during the Franco-Prussian War (1870–1871).

Although plausible—after the government of Napoleon III had fallen and his

1

Preface
armies had surrendered, Leon Gambetta, the French political leader who rallied

France against the Prussians escaped from Paris by balloon over the surrounding

Prussian army—recent research has shown that the story of the wounded Parisians

being evacuated by balloon is false.

Perhaps mildly embarrassingly to the aerospace medical community, the person likely responsible for giving the story credibility is one of the medical community’s major icons, Dr. Harry Armstrong. The story appeared in the highly

influential textbook, Principles and Practice of Aviation Medicine that was published in 1939 and written by Armstrong.4 Dr. Armstrong obtained his medical

degree from the University of Kentucky and also did graduate study in Canada.

He was a pioneer flight surgeon and in the early 1930s founded the Physiological

Research Laboratory at Wright Field, the forerunner of the current Aeromedical

Research Laboratory at Brooks AFB. He later served as the second surgeon general of the U.S. Air Force. Far more important than his erroneous history, however, is the fact that, as his biographical data suggests, he was highly representative

of the group of military doctors who early in their careers correctly envisioned the

potential of the rather rudimentary aeronautical technology then available for saving lives in war and peace.

2

A History of Aeromedical Evacuation in the U.S. Air Force

Dr. Harry Armstrong.
The movement of the wounded and sick by airplane originated after the successful conclusion of Wilbur and Orville Wright’s 1903 experiments with a heavier-than-air machine at Kitty Hawk. Almost immediately, people tried to apply the

new science of aeronautics to a realm of human activity as old as man himself—

the art of healing. The initial focus was on healing within the equally ancient context of warfare.

What emerged from these initial attempts was the establishment of a symbiotic link between the rapid development of aeronautical science, embodied in aircraft of increasingly greater performance capabilities, capacities, and comfort, and

the equally rapid developments in medicine, which by the end of the nineteenth

century had been placed on a new scientific basis by the work of Louis Pasteur,

Robert Koch, and Joseph Lister. Their cumulative and revolutionary work helped

provide physicians with an understanding of bacteriology and gave them the

wherewithal to perform surgical procedures that as recently as the Civil War

would have resulted in massive, fatal infections.

Exemplified by the work of Walter Reed and William C. Gorgas, the conquerors of yellow fever, and advanced during Brig. Gen. George C. Sternberg’s

tenure as surgeon general (who had worked with Koch and himself been trained

as a bacteriologist), the medical revolution essentially triumphed in the Army by

the turn of the twentieth century.5 Medical laboratories now became essential parts

of the “sanitary train” of field hospitals and ambulance companies to medically

support the army in the field.

The earliest known attempts to build a heavier-than-air machine to transport

patients occurred between 1909 and 1910 in the United States, but indifference

within the War Department caused these efforts to be quashed. It was during

World War I that Americans first applied aeronautics to medical requirements.

The focus was on a fairly narrow problem: how to provide more timely medical

care for their aviators. The entry of the United States into World War I led to plans

for a rapid expansion of Army aviation, with a concomitant increase in the number of training accidents, many occurring in remote locations. The solution, apparently arrived at independently by personnel at several flight training locations,

was to reconfigure tactical and training aircraft into crash rescue vehicles.

In Europe, a few persons who deservedly can be called visionaries saw aviation more broadly. They saw it as providing several new dimensions to the sanitary services of their armies that were responsible for the rescue, movement, and

medical treatment of war’s casualties. The French converted a number of tactical

aircraft into air ambulances which, although finding very little use in Europe during World War I, rapidly found favor in the colonial conflicts that followed.

In both Europe and the United States, although in somewhat different ways,

World War I was the catalyst to initiate the development of aircraft as a tool for

evacuating the wounded and sick. Air evacuation would complement the ground

methods that had become routine by the end of the war, which utilized human- or

animal-borne litters, horse-drawn or motor-powered ambulances, and hospital

3

The History of Aeromedical Evacuation in the USAF
4

A History of Aeromedical Evacuation in the U.S. Air Force

trains and ships. The relatively small-scale but practical applications of aviation

to medicine in the form of air ambulances on both sides of the Atlantic established

the nexus that was to exist between aeronautical advance and the growth of medical knowledge, equipment, and procedures so notable in the post–World War I

era.

As aircraft design and capability advanced during the interwar years, physicians on both sides of the Atlantic involved in the new field of aviation medicine

examined how the inherently severe characteristics of this new environment

might affect patients. In an attempt to identify medical standards that should govern which patients could and could not be moved by aircraft, physicians discussed

the effects of lowered atmospheric pressure, reduced partial pressure of oxygen,

declining temperature as aircraft climbed to higher altitudes, and even the effect

of engine-induced vibration and noise on various types of wounds and illness.

However, aviation medicine—not necessarily a fully accepted subset of military

medicine—struggled to establish itself within the Army Medical Department.

Regardless of the work of enthusiasts for air evacuation, acceptance within the Army

would depend on how this means of evacuation was perceived by the medical establishment of the time. The basic question was how air ambulances would fit into the

Army’s established chain of evacuation. The answer would be affected to some

degree by the attitude of the traditional Army toward the Air Service—or the Air

Corps, as it was renamed in 1926—and toward aviation as a military capability.

The Evolution of the Army’s Chain of Evacuation

With the advent of organized mass armies during the French Revolution,

1789–1799—which were raised, maintained, and sent into battle in the name of

the modern nation-state—the problem of how to succor the wounded and sick

assumed two additional aspects with which European armies had not previously

had to concern themselves. The first was unique in that it dealt with maintaining

the morale of the new citizen soldiers who increasingly needed to be offered at

least some hope of survival if they were to be wounded or become sick. The second issue, that of manpower, derived from the nature of revolutionary and mass

warfare in Napoleon’s time and would later became important in the United States

during the Civil War. It culminated in World War I when the scale of human

wastage on the western front—exemplified by British losses of almost 60,000

casualties on the first day of the Battle of the Somme in 1916—made replenishing manpower the key to staying in the fight. Thus, even more than in past wars,

the preservation of the armies’ strength in manpower through timely medical

treatment of its members became critical. Lightly wounded men or those who

could be expected to recover in a reasonable amount of time were valuable

resources and needed to be recovered from the battlefield and treated so they

could be returned to the army as soon as possible. For this purpose, they needed

to be kept near the battlefield. Men who were more seriously incapacitated were
sent to permanent hospitals farther away from the fighting. Col. T. H. Goodwin, a

member of the British Royal Army Medical Corps Commission sent to the United

States in 1917 to inform his new allied counterparts what to expect, gave a series

of lectures at the U.S. Army Medical School. He stated:

We must remember that the whole object of the medical service

in war is to provide fighting men for the fighting line, to keep

them fit, and, if sick or wounded, to make them fit and ready for

further fighting as soon as possible. If all cases, including those

of a slight nature, were sent down to the base, there would be

considerable delay in getting them back to the firing line and

consequently much avoidable wastage [i.e., loss of manpower]

would take place.6

To be sure, eighteenth-century monarchs also had to be concerned about

unnecessary casualties among their soldiers because armies were expensive. Their

armies were frequently fleshed out with mercenaries, and in a preindustrial age,

arms, equipment, and the army’s logistic train were costly. Soldiers usually came

from the lower levels of society, had no sense of national identity, and in many

cases had been pressed into service. European kings could generally assume that

order would prevail in their armies’ ranks, and they could disregard the morale of

the individual soldier because savage discipline would keep him and his fellows

literally in line during in combat, as well as figuratively at other times.

Illness, however, was a different matter. With limited medical knowledge

then possessed by European physicians, only a small number of preventive

actions could be taken, at least early in the eighteenth-century. Disease could

quickly decimate an army, and it might also affect the enemy force as well. In fact,

it is estimated that 90 percent of the deaths in George Washington’s Continental

Army and 84 percent of the British deaths during the Revolutionary War were

caused by illness, in spite of Washington’s success in having his entire army inoculated in 1777 to curb a deadly outbreak of smallpox among his troops and his

efforts to ensure the addition of certain foods to his soldiers’ diets as an antidote

to scurvy.7 British army hospitals were the models available for the Continental

Army Medical Department, and by the time of the American Revolution they

were noted for an emphasis on sanitation, good air and ventilation, and the prevention of overcrowding; critical knowledge of what caused infections in wounds,

however, was not yet available.8

The advent of citizen soldiers in the American and French revolutions raised

the issue of morale and an at least a philosophical commitment to the greater

worth of the soldier as a citizen and member of a group identifiable with a nationstate. As the nineteenth century wore on, the latter characteristic tended increasingly to give the soldier special cachet, at least in comparison with men from other

national groups and certainly when compared with his counterpart in the dynastic

armies of the previous century. Although the army of Louis Napoleon’s Second

5

The History of Aeromedical Evacuation in the USAF
Empire at midcentury was a professional force, the French Zouaves, according to

a French line officer, could say to their superior in 1870, “we are willing to fight,

but don’t let us die like dogs if we are wounded,” and expect that their call would

not go totally unheeded.9 With a commitment to provide the wounded and sick

with medical care, it became necessary to evacuate casualties to hospitals staffed

predominantly with surgeons. Surgeons were required because medical knowledge at the time was such that amputations were the most frequently performed

medical procedure used to save the lives of men with shattered limbs.

Caring for the sick and wounded posed enormous logistic problems, particularly before the advent of railroads. The eighteenth century’s fixed and rolling

magazines carrying supplies to support the army were never enough by themselves to fill an army’s needs under normal circumstances. Adding the requirement to provide care for the wounded and sick could threaten a breakdown of the

existing system and severely hamper operations.10

Evacuation of the wounded and sick from the field of battle prior to the

Napoleonic era was somewhat haphazard and undertaken chiefly by means of

horse-drawn vehicles. This ground mode persisted into the twentieth century,

although during World War I it expanded to vehicles powered by internal-combustion engines. What was conspicuous by its absence was the lack of a wellarticulated system for making the evacuations. Napoleon’s surgeon general,

Baron Dominique Larrey, remedied the fault in 1797 when he organized a system

of ambulances volantés, flying ambulances, units equipped with wagons to

remove the wounded of the Grande Armée from the battlefield.11

Larrey’s ambulances were reportedly later adopted by the other European

powers. The defeat of Napoleon and the Vienna Settlement of 1815 produced

nearly a half century in which Europe experienced no general war, so when the

European powers fought again at midcentury in the Crimea, the scandalous conditions for wounded and sick that Florence Nightingale discovered showed that

the British in the interim had devoted little real attention to dealing with the problems of evacuation and treatment. In what would provide a precedent for a subsequent U.S. organization, the private British Sanitary Commission was created

and played a major role in helping expose and ameliorate these differences.12

The American Civil War—in which armies of unprecedented size experienced high casualty rates from battles and epidemics of various sorts, including

malaria, scurvy, and even smallpox—initially exposed the same kind of medical

malaise. Under pressures from public opinion and the newly created private voluntary Sanitary Commission, the Army Medical Department, despite considerable

initial resistance on the part of its surgeon general, Clement A. Finlay, at length

developed an evacuation system and system of treatment centers that would be the

basis under which the Army Medical Department would enter the twentieth century. The process was aided immeasurably by Finlay’s retirement in 1862 and the

accession as surgeon general of Brig. Gen. William A. Hammond, who supported

the new approach.13

6

A History of Aeromedical Evacuation in the U.S. Air Force
Surgeon Jonathan Letterman, medical director of the Army of the Potomac,

was responsible for creating a professional military ambulance corps of military

men under the control of the Army Medical Department. Light two-horse ambulances, manned by two men and a driver and equipped with two stretchers, were

deployed with regiments and corps to bring the wounded and sick from the field

to dressing stations. From there they were generally transported to field hospitals,

and from there to Army general hospitals, as necessary. As the war progressed,

trains or ships became equipped or had been designed specifically to evacuate the

wounded. Surgeons and hospital attendants had previously been required to attend

evacuees, so Letterman’s system meant that fewer regimental surgeons and attendants were drawn from the battlefield, and the need for tents and equipment for

field and depot hospitals was reduced.

Letterman also issued general instructions to govern the operation of a system of field hospitals and successfully addressed what had been a deficient system for distributing medical supplies. He also sought to facilitate the documentation of patients’ medical histories so that the Army could track each patient’s treatment, condition, and location as he passed through the system until his discharge.

The record would be sent with him when he was evacuated or transferred from

place to place. As the historian of the Army Medical Department has noted of this

development, the most important obstacle to the creation of an efficient evacuation system was overcome when the medical department recognized that a formal

organization, careful planning, and trained and disciplined personnel were necessary. The support of Gen. George B. McClellan, then commander of the Army of

the Potomac, ensured that the department would have the control necessary to

make Letterman’s system work, and ultimately led to his approach being adopted

throughout the Army late in the war.14 In view of Baron Larrey’s pioneering efforts

in this regard, Letterman’s ambulance corps served as a model for European

armies and their sanitary services until the advent of World War I, and both the

French and Prussians adopted the system during the Franco-Prussian War.15

Letterman’s attitude toward general hospitals tends to exemplify the inherent

tensions in military medicine between a doctor’s desire to heal the sick and

wounded and his military responsibility to his commander to ensure that the unit

has sufficient personnel to perform its mission. Letterman favored keeping the

wounded in field hospitals under the care of their own surgeons because he

strongly believed that “life in a General Hospital tends to destroy the good qualities of a soldier.”16

In the interval between the end of the Civil War and the beginning of World

War I, Letterman’s chain of evacuation was of little relevance to the kinds of military campaigns that the Army was called upon to fight. In relatively small-scale

actions against Indians in the West and brief campaigns in Cuba and the

Philippines, few battle casualties required evacuation, and the Army Medical

Department quickly became engaged in trying to deal with endemic tropical diseases. Division-sized maneuvers by the sanitary troops of the 12th Provisional

7

The History of Aeromedical Evacuation in the USAF
Division in November 1916, the first large-scale movement of troops since the

Civil War, found that the sanitary train of ambulances and mobile hospitals was

largely dependent on horse-drawn vehicles.17 Given the scarcity of paved roads in

the country at the time, this was not as backward as it might seem, but it does,

however, draw attention to another type of casualty evacuation—of wounded and

sick horses and mules—which had to be included in evacuation planning.18

By contrast, the British Royal Army Medical Corps ambulance companies,

while using the same hand litters and horse-drawn vehicles to move wounded and

sick away from the front lines, were heavily motorized to transport casualties

from field hospitals to clearing stations, where their further treatment would be

determined. Operating in a European environment that featured a dense network

of metalled roads, each motor ambulance unit was equipped with fifty motor

ambulances, four touring cars, eight motorcycles, and four trucks, including one

for repairs. From the clearing stations, casualties whose recovery times would be

too long were evacuated by rail to more permanent hospitals on the continent or

by hospital ship to similar facilities in Britain.19

The Origins of Evacuation by Aircraft

Although the Wright brothers were the first to systematically apply scientific

principles to the problems of controlled flight by a heavier-than-air machine, the

international center of interest in aviation at the turn of the century lay in France,

focused in the Aero-Club de France which had been founded in 1898 by balloonists. French aviation enthusiasts shifted their attention to heavier-than-air

machines under the stimulus of the Wright brothers’ initial and successful 1902

experiments with gliders, news of which reached Paris through Octave Chanute,

a successful, French-born civil engineer who had become another aeronautics pioneer in the United States. His description, though actually somewhat garbled, of

the Wright brothers’ experiments, succeeded in engendering a burst of nationalistic feeling characteristic of contemporary educated Europeans. The bombastic

pronouncements of Ernest Archdeacon, a wealthy lawyer and balloonist, conveyed in hyperbolic fashion the attitudes of many Aero-Club members when he

wrote

Will the homeland of the Montgolfier [the first balloonists] suffer the shame of allowing the ultimate discovery of aerial science—which is certainly imminent, and which will constitute

the greatest scientific revolution since the beginning of the

world—to be realized abroad?20

The interest stirred by Chanute’s writings and such pronouncements as

Archdeacon’s led within months to the Aero-Club becoming the headquarters for

a band of experimenters so determined to fly that they took to calling themselves

les aviateurs militantes, militant aviators.21

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A History of Aeromedical Evacuation in the U.S. Air Force
Although French enthusiasts eventually came with some grace to acknowledge their loss to the Wrights, their passion for aviation was undimmed and continued unabated until the beginning of World War I. In 1909 Louis Bleriot crossed

the English Channel by air, a demonstration that had profound implications for

future warfare and the security of Great Britain. Among other Europeans who had

begun to look at more benign wartime applications of the new flying machines

was Maj. Gen. C. de Mooy, chief of the military medical service of the

Netherlands. Well before the Wright brothers flew, General de Mooy had been

thinking about how to transport the wounded in greater comfort, and in 1910 he

formally proposed using balloons to raise stretchers into the air and to have a

horseman pull along the balloon with its suspended patient.22

As early as February 1912, Dr. A. Duchaussoy, founder and secretary general of L’Association des Dames Françaises, an association of Frenchwomen who

served as nurses in wartime, proposed to the association’s annual convention that

progress in aviation had now reached the point when a study should be conducted of how balloons, dirigibles, and airplanes could be used to find, rescue, and

transport the wounded during hostilities. The doctor also announced that the question would be placed before the next international conference of the Red Cross

scheduled for Washington, D.C. He also proposed that the association fund some

experiments, but in spite of an enthusiastic approval of this proposal, not enough

money was collected.23

Thwarted in his attempts to conduct actual trials, Dr. Duchaussoy managed to

assemble a meeting of members of the association’s council to discuss the idea at

its Paris headquarters. Participating were representatives of French military aviation and medicine, including several senior medical officers and a representative

of the war ministry’s sanitary service. This group constituted itself as a study commission. On May 23, 1912, it submitted a report to the minister of war recommending, among other things, that each army corps be equipped with ten biplane

flying ambulances, which the commission estimated would provide each corps

with the capability to transport either 200 wounded if on litters, or 300 if seated.24

Because such use of aircraft raised questions regarding their protection and neutrality under international law, the association also formally raised this issue with

the Red Cross and the ministry of war, and it drafted a proposed regulation to govern flying ambulances.25 This was published in June 1912 in Caducée, the French

army medical and surgical journal.26

The first Geneva Convention of 1863, to which the United States had acceded in the previous year, established that military ambulances, hospitals, and the

overall process of evacuating the wounded and sick was to be considered neutral,

and that the associated facilities and personnel were to be protected against

restraint or harm. The convention provided that this protected status was valid

only if the personnel and facilities were and remained solely involved in succoring wounded and sick solders, and if the hospitals, ambulances, and personnel

involved were identified by wearing or being marked with the distinctive symbol

9

The History of Aeromedical Evacuation in the USAF
of a red cross on a white background. Should these functions change and become

hostile to the enemy, Geneva protections were abrogated. In 1906 the Geneva

Convention extended these protections to mobile sanitary formations, which

included vehicles belonging to these formations; by definition, aircraft were not

included.27

In August 1912, almost certainly as a result of the Duchaussoy commission’s

proposals, Dr. Emile Reymond, a physician and pilot who was a member of the

governing council of L’Association des Dames Françaises and a senator in the

French National Assembly, was ordered by the director of the French Sanitary

Service to participate in army maneuvers on September 16–17, 1912, to test how

to identifygroups of wounded from the air and then how to locate them on the battlefield. Reymond and the director had previously discussed this question, and

although they had agreed that aircraft capable of evacuating wounded would be

built in the future, they decided the most pressing current issue requiring investigating was how aircraft then available might be used to assist the wounded.28

Support for the idea of using aircraft to locate the wounded also came from one

of de Mooy’s students, Jeanne Marvignt, later a nurse and the first Frenchwoman

to obtain a pilot’s certificate, who made the same proposal independently, also in

1912.29

Reymond’s enthusiastic and detailed accounts of his successful efforts convinced at least the National Aero League. It passed a resolution on November 12

inviting the government to take the initiative and convene a conference of national Red Cross societies to codify the protection and neutralization of air ambulances in a new Geneva Convention. Charles Julliot, a lawyer and member of the

league’s governing council and the Aero-Club as well, raised this issue when he

published an article in November 1912 on sanitary aviation and the Red Cross

conventions. He thereafter tirelessly promoted the neutrality of air ambulances

until the Geneva Convention of 1929 extended this protection.30

The implicit faith in the efficacy of international agreements that animated

these discussions seems to have been joined with a concept of war, perhaps

derived from memories of the Franco-Prussian War, that would tend to be invalidated in the future conflict of 1914–1918. This concept envisaged that future battles would be followed by withdrawal of the defeated army or by other periods of

noncombat when battlefields could be searched and the wounded retrieved in relative safety. Reymond believed that groups of wounded would congregate in such

a lull, making them easier to see.

The war ministry was less enthusiastic about air ambulances. It saw some

merit to Reymond’s experiment, but it was cool to the commission’s proposals of

May 1912 that air ambulances be built for the transport of casualties and that they

be attached the French army corps. On December 10, 1912, the minister of war

responded to these proposals in a letter to L’Association des Dames Françaises.

He stated he did not believe the idea of using aircraft to transport the wounded

was practical at that time. The only current role for aircraft, he believed, was to

10

A History of Aeromedical Evacuation in the U.S. Air Force
explore the battlefield for groups of wounded, which is what Reymond31 had

demonstrated could be done successfully. The minister’s letter officially closed

the matter for the prewar years, although unofficial interest remained high. A

French military medical officer, M. Gautier, declared in October 1913, “we shall

revolutionize war surgery if the aeroplane can be adapted as a means of transportation for the wounded.”32

During the war, the position of the war ministry was undercut in November

1915 by news that French pilots serving with the Serbian army had successfully

evacuated by air thirteen wounded and sick members of a small French expeditionary force, thus avoiding their capture by the advancing Bulgarian army. The

evacuees had been carried to safety on the Albanian coast some 150 miles away

in two-place tactical aircraft.33

In 1917 the ministry finally yielded to the entreaties of another physician, Dr.

Chassaing, who represented the city of Puy-le-Dome in the National Assembly.

Allowed to work with Justin Godart, undersecretary of the Sanitary Service, they

modified an old tactical aircraft, a Dorand AR II, at Villacoublay near Paris, to

carry two patients on stretchers, one placed above the other inside the fuselage,

behind the pilot. Purportedly, Chassaing’s earlier pleas to the National Assembly

for money to reconfigure aircraft to carry wounded soldiers had been greeted with

the withering comment, “Are there not enough dead in France today without

killing the wounded in airplanes?” Given the questionable reliability of some of

the pilots and aircraft of the time, an element of reason underlaid the scorn.

Cleverly, Chassaing showed his first air ambulance to members of the appropriate committees of the National Assembly, and he gave the chairman of the

hygiene committee of the Chamber of Deputies a 25-minute flight in the modified

aircraft. This apparently won them over. Chassaing was provided six similar aircraft for conversion, which he was allowed to use for evacuating casualties on the

Aisne front in November 1917, and also in Flanders in 1918. The government

subsequently withdrew its sanction because of the intensity of the fighting there,

and in late 1918 it allocated sixty Breguet aircraft to Chassaing for conversion to

air ambulances.34 Pictures of Chassaing’s first air ambulance showing how the aircraft had been modified to carry litters appeared in the United States in the

November 1917 issue of Scientific American.35

The scale of the fighting on the western front generated such large numbers

of casualties that the small capabilities of Chassaing’s air ambulances must have

seemed irrelevant, though they were eminently suited to the smaller requirements

of colonial warfare. Chassaing received some Breguet 14 A.2s for reconfiguration

as air ambulances, and they were used to good effect in Morocco in the early

1920s. Dr. Reymond had also suggested the value of air ambulances in the

colonies at a meeting of reserve doctors in March 1913 when he recounted the aerial search for the wounded during the 1912 maneuvers.36

11

The History of Aeromedical Evacuation in the USAF
The Emergence of the Air Ambulance in the United States

Charles Julliot, the tireless French lawyer and advocate of extending the protections of the 1906 Geneva Convention to air ambulances, had attributed the

birth of sanitary aviation to France. Conceptually and practically, that honor

belongs to the United States.37 Although the Wright brothers had less interest in

exhibiting their aircraft than in securing proprietary rights to their invention

through proper patents, in France they had been accorded recognition and admiration through a series of demonstration flights in the summer of 1908.

Demonstration flights conducted for the U.S. Army later that summer and the following year at Fort Myer, just across the Potomac River from Washington, D.C.,

resulted in the Army’s purchase of its first aircraft.38

Perhaps, and not altogether coincidentally, in late 1909 at Fort Barrancas in

Pensacola, Florida, an Army doctor, Capt. George H. R. Gosman, and an officer

from the Coast Artillery, Lt. A. I. Rhoades, used their own funds to begin construction of an aircraft specifically designed to transport patients. They planned a

side-by-side configuration to accommodate a litter patient and the doctor-pilot.39

The aircraft first flew in January 1910 as a glider; the subsequent first and only

powered flight of some 500 feet at an altitude of 100–150 feet ended disastrously

when an oil line broke. Without financial resources to proceed on their own,

Captain Gosman went to Washington to solicit the War Department for money to

continue his experimentation. According to the officer, the department thought the

idea fantastic but turned him down. Long afterward, Gosman still believed in the

project, commenting, “I clearly saw thousands of hours that would be saved by an

ambulance plane.”40

12

A History of Aeromedical Evacuation in the U.S. Air Force

A Breguet 14A.2 aircraft, of the type configured as an air ambulance.
Gosman and Rhoades were indicative of the growing interest in Army aviation and in the possibility of using aircraft as ambulances. In May 1912, Secretary

of War Henry L. Stimson received a recommendation from Army aviators that airplanes be used to transport patients. Again, no action followed.41 In October of that

year, Col. A. W. Williams, an Army surgeon, appeared before the Committee on

Transportation of Wounded in War of the Association of Military Surgeons then

holding its annual convention in Baltimore, Maryland. Williams received a favorable response to his recommendation that airplanes with specially constructed

ambulance bodies be used in wartime to transport severely wounded soldiers

requiring immediate treatment to emergency operating stations.

Appearing with Williams before the committee at his request was Lt. Henry

H. Arnold, the future World War II chief of the AAF. In a memoir written much

later, Williams reported he had raised the subject of airplanes as ambulances in

conversation with Arnold the preceding summer in Philadelphia and that, at

Arnold’s invitation, he had flown with him as a passenger in a hydroplane over

Washington, D.C., just a week before the Baltimore meeting.42

The reaction of the Baltimore Sun to Colonel Williams’s proposal, however,

was strongly negative. In words similar to those with which Dr. Chassaing’s proposal would be greeted several years later in France, the Sun editorialized, “the

hazard of being severely wounded was sufficient without the additional hazard of

transportation by airplane.”43 When the United States entered the war, Williams

was appointed president of the new Army Ambulance Board, and in this position

he undertook to secure aircraft for use as air ambulances by the Army Medical

Department, only to be told that all airplanes were needed for combat purposes.44

Whatever the official policy of the War Department, necessity soon prompted similar but uncoordinated and seemingly spontaneous responses to the frequent

accidents by student pilots at training bases as the Air Service began to expand

rapidly in preparation for World War I. When the United States declared war on

Germany in April 1917, the Aviation Section of the Signal Corps, which constituted Army aviation, consisted of 65 officers and 1,120 enlisted men. It conducted flying activities with some 200-odd aircraft which were mostly training types

and generally obsolete. At the time of the armistice, some nineteen months later,

the new Air Service comprised some 190,000 officers and men—112,000 in the

United States and 78,000 overseas—and more than 11,000 aircraft.45

In the interim, thousands of applicants for flying training were processed at

sixty-seven examining centers throughout the United States using standards

developed by a panel appointed by Surgeon General Rupert Blue and promulgated by the War Department in May 1917. Lt. Col. Theodore C. Lyster headed the

panel and would later be hailed as the father of aviation medicine.

In 1914, the seven-year-old Aviation Section of the Signal Corps had begun

a search for a set of physical standards more relevant to the requirements of flying than the standards the Army used when normally selecting recruits. Unable to

obtain the criteria that other nations used, Dr. Blue developed his own on the basis

13

The History of Aeromedical Evacuation in the USAF
of standard physiology texts. He incorporated existing requirements for vision and

hearing as defined in Army and Navy regulations. When the Army began to

expand in 1916, the board headed by Colonel Lyster began to develop the examination that was promulgated in May 1917. After the United States entered the

war, the surgeon general gave Lyster the responsibility for recruiting for aviation.

Valid standards were critical because the British discovered that 60 percent of

the fatalities suffered by their aviators during the first year of the war were due to

physical defects, a situation obviously reflecting deficiencies in the selection criteria. This was perhaps not surprising, given the lack of knowledge about the

physiological and psychological demands of this new medium. The British

learned from experience and cut the death rate radically in successive years

through a program that sought to determine what special physical and mental

stresses affected aviators.46

The United States approached the selection issue by identifying and applying

the most relevant standards from the outset. The question posed by British experience was, what are they? Using Lyster’s standards, some 71 percent of the applicants who wanted to fly for the U.S. Army were accepted, but what Harry

Armstrong called the appalling death rates suffered by flying cadets at the train14

A History of Aeromedical Evacuation in the U.S. Air Force

Lt. Col. Theodore C.

Lyster, father of aviation medicine.
ing centers in the United States and among the allies in France indicated to

Colonel Lyster that more analysis was needed.47

When he became the first chief surgeon of the Aviation Section of the Signal

Corps in September 1917, Lyster recommended that a permanent research board

be established to investigate all conditions affecting the physical efficiency of

pilots, to conduct experiments and tests at the several flying schools, to provide a

suitable apparatus for supplying oxygen, and to act as a standing organization for

instruction in the physiological requirements of aviators.48 The result was the

foundation of the aviation medical laboratory at Mineola, New York, and with it,

the implicit acknowledgement that medical aspects of aviation were different

from those of the traditional Army branches. Somewhat later, two events marked

an even more explicit recognition of those differences: establishment on January

9, 1918, of a separate medical service for the Aviation Section of the Signal Corps,

independent of the control of the medical department of the Army; and the official designation of specially trained doctors as flight surgeons.49

Although recruiting was successful, a disturbing pattern of accidents emerged

from the training bases. The Army had entered the war with three airfields in the

United States: the Aviation School, founded in 1912 on North Island, San Diego,

California; a facility at Mineola, New York, later designated Hazelhurst Field,

which trained candidates for the National Guard and the Reserves; and a temporary training field at Essington, near Philadelphia, Pennsylvania. During the war,

however, the Army acquired forty-five additional flying fields, nineteen depots,

and various other facilities scattered across the country. Many of the new flying

fields were located in sparsely settled areas in the South and Southwest to capitalize on the region’s advantageous flying weather. These included Brooks Field

and Kelly Field at San Antonio, Texas; Gerstner Field at Lake Charles, Louisiana;

and Ellington Field at Houston, Texas.50

Having met the Aviation Section/Air Service selection standards, cadets still

had to learn how to operate in an unfamiliar medium. In the process, many accidents occurred. This should not have been surprising given the society from which

the cadets came. Few if any of them were familiar with internal-combustion

engines, the speeds that could be attained by vehicles so powered, or the principles of aeronautics, the knowledge of which was vital to safe control of the aircraft in flight. In addition to the considerable unfamiliarity with aeronautical principles, the aircraft themselves were not totally reliable; furthermore, they were

underpowered, which exacerbated problems of aircraft control.

From April 6, 1917, when the United States declared war on Germany, until

January 1, 1920, the Air Service suffered 2,311 airplane crashes that killed 135

men and injured another 303. An analysis of these crashes for which flight surgeons filed reports showed that almost half were characterized as having been due

to bad judgment, somewhat fewer were attributed to engine trouble, far less were

deemed to have been unavoidable, and an insignificant number were reported to

be caused by pilot inexperience. Most accidents occurred during landing,

15

The History of Aeromedical Evacuation in the USAF
although substantially more accidents occurred fifteen or more miles away from

the home station than occurred closer to the training site.51 Such crashes, usually

involving aircraft that went down in remote areas with either poor or no access to

nearby roads, were particularly troublesome because it was extremely difficult to

provide timely medical care to surviving pilots and passengers. The ultimate solution to this problem of crash rescue was to convert tactical aircraft to carry injured

pilots, a solution that seems to have been independently arrived at by commanders and medical personnel at several flying training fields in early 1918.

Flying medical personnel to crash sites to provide immediate first aid before

the arrival of an ambulance was practiced in Europe. It was a procedure that a

senior British Royal Air Force surgeon, writing in the autumn of 1918, claimed to

have originated, asserting that he had conducted between thirty and forty such

journeys.52 Given fortunate conditions and geography, it was a fairly obvious solution to the problem of providing timely assistance to crash victims. It was one that

Maj. W. R. Ream, a flight surgeon stationed at Rockwell Field, San Diego, reported to Chief Surgeon Lyster that he had put into effect on February 12, 1918, without having previously consulted with Lyster.53 The procedure had the potential for

providing timely aid, but if ambulances were unable to reach the area, or if the

injuries of the downed airmen were too serious to permit evacuation over rough

terrain or roads, then a major and perhaps fatal problem remained.

This was of particular concern to Capt. William Ocker who was in charge of

flying training at Gerstner Field, Lake Charles, Louisiana. According to Ocker,

the field was located in low, swampy country surrounded by bayous. The area had

few roads, none were good, and all became impassable after heavy rains. The first

flying accident by a Gerstner pilot convinced Ocker that a means for getting surgeons to crashes, as well as transporting patients back to a hospital, was a necessity.

As early as February, 1918, it was evident to me that airplane

transportation was the only way of getting to the site of crashes. Authority was therefore obtained to convert a JN–4 airplane

into an ambulance. This plane demonstrated its great usefulness

at once.54

Enlisting the help of Maj. Nelson E. Driver, a reserve medical officer, Ocker

directed that a standard Curtiss JN–4 training plane be modified to accommodate

a patient in a semirecumbent position in the rear cockpit. Sometime during the late

winter of 1918 Driver and Ocker made the first recorded aeromedical evacuation

in the United States.55

It is not known what role, if any, Dr. Chassaing’s air ambulance experiments

in France may have played in the United States in initiating the development of

aircraft for the same purpose. The experience of at least one Air Service surgeon

on duty at Mather Field, California, in 1918, who acknowledged having seen the

Scientific American article of November 1917, suggests that Chassaing’s experi16

A History of Aeromedical Evacuation in the U.S. Air Force
ments probably had no effect at Gerstner Field, but it is likely that other information channels were available through which related communications could have

passed.

Capt. Norvelle Sharpe, who before his assignment at Mather had been the

chief surgeon at Gerstner Field, reported in an Annals of Surgery article published

in November 1918 that he had studied an air ambulance constructed at Gerstner

during his earlier tenure, but he was not convinced from either his own observation or opinions expressed by medical, flying, or engineering officers that an air

ambulance was the best aircraft for the task. His interest was based on personal

observations that, although providing medical assistance to aircraft accidents near

a flying field presented no major difficulty, crashes at more remote sites, which

because of obscuring environments could take time to reach, or even to find, and

were quite different. They entailed an enormous waste of time and effort together

with an unavoidable prolonging of the suffering and shock to the crash victim,

who frequently suffered serious injury to his cranium, spine, thorax, and

abdomen.56

It was evident to Sharpe that the usual ambulance equipment and service provided were inadequate, and the most satisfactory solution would be to replace

motor ambulances controlled by the Army Medical Department with ambulance

aircraft controlled by the Air Service. He noted the implicit issue of whether such

aircraft should be dedicated solely to ambulance work or whether they should be

used for other purposes as well, but he took no position. He did offer his own suggestion for configuring a JN–4D training aircraft to make it more effective when

being used as an ambulance. Sharp’s engineering drawing shows a JN–4D modified to carry one patient recumbent on a litter inside the fuselage behind the pilot’s

17

The History of Aeromedical Evacuation in the USAF

A Curtiss JN–4D, a training plane modified to accomodate patients, circa 1918.
cockpit. In a lengthy footnote, he revealed that he had written to the librarian of

the surgeon general’s office on August 6, without specifying the year, for information on ambulance airships, but that the librarian could find “nothing of this

sort on file.” Sharpe pursued the matter, learning from a troubleshooter that he had

seen such an aircraft in Great Britain the year before and that a memorandum concerning the plane had recently appeared in Popular Mechanics. Perusal of issues

for 1918 revealed no such memorandum, but Sharpe indicated that he did find the

November 24, 1917, issue of Scientific American with its brief account and pictures of Chassaing’s experiments at Villacoublay.57

Several things are interesting about Sharpe’s account. His letter to the surgeon general’s office followed the publication of the Scientific American article

and the construction of the first air ambulance at Gerstner Field in early 1918. He

wrote in August 1918, which strengthens the presumption that the Gerstner air

ambulance was strictly Driver’s and Ocker’s idea. Had Sharpe seen the Scientific

American article, nothing precludes either Driver or Ocker from having done so

too. With regard to a possible British source for the idea, assuming that the troubleshooter was truthful, British cadets were learning to fly in the United States,

and their presence meant the existence of liaison officers who constituted an information channel through which such communications could have passed.58

Aside from the issue of where in the United States the idea for air ambulances

originated, Sharpe’s comments are all the more important because they tend to

typify the concern of the more clinical approach of the aviation surgeon. His focus

was on wounded aviators, in contrast to the tendency of most military surgeons

who focused on medical treatment to relieve pain and suffering and then return

the soldier to duty. It seems clear that flight surgeons got caught up in the early

mystique of aviation, which is why they were attracted to aviation medicine in the

first place.59

Flight surgeons were charged by regulation with acting as advisers to the

commanding officer of flying schools and squadron groups and, although formally under the post surgeon, were given the freedom of independent initiative in all

questions regarding the flying fitness of aviators or cadets. Subject to approval by

the commanding officer, flight surgeons were expected to institute such measures

as rest periods, recreation, and temporary excuse from duty as they deemed advisable. To ensure that the flight surgeon knew the condition of his charges, the regulation specified that “he will live in as close touch with the aviators and cadets

at his station as is consistent with the conditions.”60

After completion of training as flight surgeons and assignment to flying fields

for duty, flight surgeons were encouraged to take flying instruction and qualify as

pilots. When placed on flying status, flight surgeons were required to fly a minimum of ten flights a month, either as a passenger or pilot. Being required to fly at

least as a passenger to maintain flying status clearly caused flight surgeons to

identify with aviators and aviation. The division of perspective within the ranks

of Army Medical Corps surgeons created by this familiarity would grow.61

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A History of Aeromedical Evacuation in the U.S. Air Force
Additionally, Sharpe illuminates for the first time an issue regarding aircraft

used as ambulances that would persist throughout the subsequent history of

aeromedical evacuation. It was whether ambulance aircraft should be dedicated to

the task, that is, reserved exclusively for it, or whether they should be available

for other missions. Beyond the potential for an impact on military operations, this

issue went to the heart of extending protections to ambulance aircraft under the

Geneva Convention.

A lack of knowledge of Chassaing’s experiments on the part of the surgeon

general’s office may indicate that the surgeon general’s librarian had not noticed

the brief article on the Villacoublay tests in the 1917 Scientific American because

the library itself did not subscribe to this periodical.62 What is odd is the denial of

any data on ambulance airships. The surgeon general had to be well aware of the

Gerstner Field air ambulance by mid-1918 when, by chance, similar aircraft were

deployed at all U.S. Army flying fields.

On June 26, 1918, Congressman Ladislas Lazaro, a physician and representative of the congressional district in which Gerstner Field was located, had written to Maj. Gen. William L. Kenly, director of military aeronautics, citing a newspaper story about air ambulances being used to rescue crash victims at the Army’s

flying fields. Identifying his own medical background, Lazaro indicated he

thought this was a good idea and was anxious to know if it was being done at all

the Army fields, particularly at Gerstner Field.63 The whole subject was clearly

news to the Kenly, who was an artilleryman recently returned from France and

given the responsibility for training officers and enlisted men for aviation duty.

Not a pilot, Kenly had become the director of military aeronautics on May 20, the

month before receiving Lazaro’s letter, when President Woodrow Wilson removed

Army aviation from the jurisdiction of the Signal Corps and created two new

agencies under the Secretary of War—the Bureau of Aircraft Production, and the

Division of Military Aeronautics.64

Kenly’s initial reaction was that air ambulances were an excellent idea, and

he asked the commanding officer at Gerstner Field for particulars.

Have you airplane ambulance in use at your station? Wire particulars with reference to any use you have made of an airplane

in conjunction with ambulance or first aid work.65

His query was timely for reasons other than obtaining information to satisfy a congressional inquiry. For the preceding several months, pleas for heavy ambulances

had been made to Colonel Lyster’s office from surgeons at the training fields. The

surgeons wanted better-sprung vehicles capable of traveling over rough terrain

with less severe motion than that experienced in the current ambulances, which

could add serious injury to crash victims.

Colonel Lyster sent an urgent request to the Army surgeon general on May 18

that a special type of ambulance, preferably a heavy-duty Packard or White vehicle, be supplied for use at all flying fields, and he attached extracts from the sur19

The History of Aeromedical Evacuation in the USAF
geons. Typical was one from Maj. Isaac Jones at Carruthers Field near Fort Worth,

Texas, who had worked with Lyster in developing the Aviation Section examinations. Jones characterized the current ambulance as abominable and the aerodrome as so rough that “the commanding officer and post surgeon feel very

strongly that when a man has crashed he has very little chance of being brought

safely to the hospital with these old ambulances.”66 Two days after Lyster’s memorandum to the surgeon general, Director of Military Aeronautics Kenly, in an

effort to pressure the surgeon general to respond rapidly to Lyster’s request, and

at the urging of his staff of aviators, including Col. Henry H. Arnold, officially

noted Lyster’s action. In a letter to Lyster intended to be sent with Lyster’s original memorandum to the surgeon general, Kenly heartily endorsed Lyster’s efforts

and added his own expression of dissatisfaction with the present ambulance

equipment at the flying schools, which he contended were in most cases Ford and

GMC trucks converted into ambulances. He also wanted to impress upon everyone the necessity of obtaining an ambulance capable of transporting an injured

aviator from place to place at extremely high speed, because “a few seconds may

mean the life or death of the injured man.”67

Maj. Maxwell Kirby, the commanding officer at Gerstner Field, answered

Kenly’s query about the air ambulance affirmatively on July 3. Twelve days later

he supplemented his earlier communication with two photographs and a tracing

showing the plan of the rear cockpit of the Gerstner air ambulance. Kirby wrote

that it had been continuously in use since approximately May 1, had been found

to be satisfactory, and had been used “to great advantage since completion.”68 In

response, on July 27, 1918, Kenly issued a directive to the commanding officers

(COs) of all flying fields. He informed them that they would soon receive photographs and drawings from the CO of Gerstner Field containing all information

necessary to build an ambulance plane, which had been found to be very useful in

responding to accidents occurring at distances difficult to reach quickly by automobile. With this data, each CO was to construct such a plane and put it into operation as soon as possible.

Three days earlier, Kenly’s office had finally responded to the questions

posed by Congressman Lazaro, which had started the chain of events that produced the general’s directive. Lazaro was told that air ambulances had first been

adopted at Gerstner Field and had proved so satisfactory that they were being

adopted at all flying fields.69 A month later, Maj. W. H. Frank, the CO at Ellington

Field, Houston, Texas, informed Kenly in a letter that, with reference to his directive and the Gerstner air ambulance, Ellington had for several months been operating an air ambulance of its own design. The Ellington air ambulance had a number of advantages over Gerstner’s. Most important was the fact that patients could

be loaded lying on a stretcher in a specially constructed compartment in the fuselage in back of the rear cockpit, whereas patients carried in the Gerstner air ambulance had to be carried in a sitting position. In his letter to Kenly, Major Frank

included six photographs showing various stages of the loading procedure which

20

A History of Aeromedical Evacuation in the U.S. Air Force
look remarkably like the configuration of the first French air ambulance of Dr.

Chassaing.70

The rapid proliferation of differing models of air ambulances—a third variant was flying at Kelly Field by May or June of 1918, the result of an initiative of

the base flight surgeon, and a fourth, also sometime in 1918, at Eberts Field,

Lonoke, Arkansas, the design of another flight surgeon, Maj. S. M. Strong—led

to attempts to conduct a census of such aircraft and to establish a standardized

configuration.71 Col. Albert Truby, who became chief surgeon of the Air Service

in 1919, called for reports from all fields with air ambulances then in use, but he

was not satisfied that any of those reported to him were totally suitable because

each required a different type of litter. He subsequently asked the Air Service

Engineering Division at McCook Field to design a plane that would accommodate

a pilot, medical officer, and two patients in standard Navy wire-basket Stokes litters.72 The result was a modified DeHavilland DH–4A that carried two patients on

litters, one above the other, with space for a medical officer in a rear cockpit, just

ahead of the litter compartment. Several of these modified aircraft were produced

for service on the Mexican border.73

Truby, whose only direct association with U.S. Army aviation was his service

as Air Service chief surgeon from 1919 to 1922, was something of a visionary in

his own right.74 His book on the history of air ambulances, published by the Air

Service in 1923, clearly envisioned the aeromedical evacuation mission as much

broader than just the crash rescue function that at the time essentially defined it.

His perspective implied that in the future a number of aircraft, each with different

capabilities, would be required to perform different aspects of the total mission.

These he specifically identified as crash rescue, as it was currently being done;

transportation of patients from isolated medical facilities to larger hospitals for

better medical treatment; casualty evacuation of the seriously wounded from the

front lines to hospitals in the rear; and the delivery of medical supplies. His view

that different kinds of aircraft were needed to perform as air ambulances began to

appear in official Air Service publications.75

Aeromedical Evacuation in the United States

during the Early Interwar Period

Commensurate with the new enthusiasm of the U.S. Army Medical

Department for air ambulances and what could be described as the emerging concept of aeromedical evacuation versus crash rescue, the Medical Research

Laboratory and School for Flight Surgeons secured authority to convert a Curtiss

Eagle aircraft into an air ambulance. Completed in 1921, the modified aircraft

could transport, in a closed cabin, either four litter-bound and two seated patients,

or six seated patients. It clearly fit Colonel Truby’s concept of a patient transporter; in fact, Truby was able to convince Army Surgeon General Maj. Gen.

Merritte W. Ireland to approve the transportation of patients from Mitchel Field

21

The History of Aeromedical Evacuation in the USAF
on Long Island to Bolling Field at Washington, D.C., for transfer to Walter Reed

Army Hospital in Washington. Brig. Gen. William “Billy” Mitchell, assistant

chief of the Air Service, had test-flown the Eagle and pronounced the whole enterprise “a very progressive step, and one that is no way hazardous.” Nevertheless,

the War Department disapproved the flight with the notation that “in case of accident, the use of airplanes for the transportation of sick and wounded soldiers when

other, safer means of transportation is [sic] available, could not be justified.”

Several weeks later, the Eagle did crash, stultifying further developments along

this line for the foreseeable future.76

The fundamental problem was money, and it would remain so during most of

the rest of the interwar period. Air Service appropriations fell from wartime

appropriations of $450 million for fiscal year (FY) 1919 to $25 million for FY

1920; to $33 million for FY 1921; to just under $20 million for FY 1922; and then

to below $13 million for the next three fiscal years, rising slightly to $14.7 million for FY 1926.77 Prioritizing available funding was difficult, and in April 1927

the Army adjutant general reported that funds were inadequate even to deal with

the continuing problem of having enough motor ambulances to provide timely

assistance to crash victims.78

In addressing aeromedical evacuation, priority went to crash rescue aircraft,

and the Air Service for the first time obtained two experimental aircraft designed

specifically for air ambulance work. The Cox-Klemin Aircraft Corporation delivered two XA–1 (experimental ambulance) biplanes in 1925. These aircraft proved

to be excellent crash rescue vehicles capable of operations into very short unpaved

fields. They could carry a medical officer and two litter patients in an enclosed

cabin behind the open cockpit, where the pilot was ensconced. The two modified

Stokes litters could be placed one above the other so that the medical officer could

attend the patients in flight.79

The Cox-Klemins performed extremely well during their relatively short

life. One was destroyed in a 1929 accident; the other met a similar fate in 1931.

They were the last airframes specifically built to be used exclusively for

aeromedical evacuation. The future would belong to transport aircraft that could

be converted, as needed, into air ambulances. This was the approach recommended by General Mitchell, Lt. Clayton Bissell, and aeronautical engineer

Alfred Verville upon their return from a European inspection tour in the winter

of 1921–1922. Based on their discovery that the British were, as standard practice, adopting passenger-carrying transport planes into air ambulances, their

report recommended that development “of a convertible multi-motored type of

troop carrier and ambulance plane should be undertaken as one of our new

types.”80 In the spring of 1923, this idea was tested successfully when litters and

medical paraphernalia were installed into a twin of the Fokker T–2 transport that

flew nonstop coast-to-coast in May, temporarily converting it into an air ambulance. Consequently, the Air Service contracted to buy nine Douglas C–1 biplane

transports equipped with attachments on the floor and walls of the passenger

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23

The History of Aeromedical Evacuation in the USAF

compartment to allow for the installation of four ambulance stretchers.81 These

specially designed transports were distributed across the United States and in its

possessions and territories where aeromedical evacuation was most useful in the

absence of a well-developed ground transportation system.

The Postwar Development of Sanitary Aviation in Europe

European activities addressing sanitary aviation after World War I were much

more vigorous and widespread than they were in the United States, and even came

to include the Soviet Union. Great Britain, France, and, to a lesser degree, Italy

were particularly active for reasons primarily having to do with their respective

colonial enterprises. Germany was a latecomer to sanitary aviation because

Germany was prohibited by the Treaty of Versailles from having an air force.

Within just a few years after its unilateral abrogation of the disarmament clauses

of the treaty, however, Germany was to demonstrate the effectiveness of aeromedical evacuation on a relatively large scale in Spain. All these developments had a

definite effect on thinking about aeromedical evacuation in the United States, a

result of the information flow across the Atlantic, a consequence of professional

meetings and reports from military observers and professional journals, especially The Military Surgeon. This journal, a publication of the Association of Military

Surgeons of the United States, frequently carried translations of foreign articles on

sanitary aviation.

Col. Robert Picque, one of the most vigorous French and European proponents

of sanitary aviation in Europe, was an honorary member of the association, and several of his articles were translated into English for publication in the journal. He

attended the annual meeting of the group in San Antonio, Texas, in November 1924.

He subsequently toured various Air Service installations and other aviation-related

locations. His visits included the School of Aviation Medicine (SAM) at Mitchel

Field; the eastern terminus of the transcontinental airmail system at Hazelhurst

Field, Long Island; and the dirigible hangar at Lakehurst, N.J. He spoke before the

association meeting, the U.S. Red Cross in Washington, and the Army and Navy and

Union League Clubs in New York. His European colleagues learned of his experiences in the United States and the state of U.S. sanitary aviation in an article he published in Les Archives Medicales Belges in 1925. Picque was unimpressed by U.S.

air ambulances, which he thought inadequate to support an aeromedical evacuation

system he considered necessary for a country as large as the United States. To his

European audience he later remarked, “we could help them in this regard.” On the

other hand, Picque was very impressed with two aspects of aviation medicine that

he encountered in the United States: the separate medical department for Army aviation, and an institution of flight surgeons.82 Sources of dialogue expanded with the

beginning of an aviation analogue to The Military Surgeon; in 1929, Louis H. Bauer

founded Aviation Medicine, the journal of the Aero Medical Association. Bauer had

commanded SAM in the mid-1920s.
Developments in European sanitary aviation also formed part of the dialogue

conducted in various international forums that arose after World War I. One was

the International Congress of Military Medicine and Pharmacy. The congress

evolved from the surgical conferences held by the allies in Paris during the war,

and it held its first meeting in Brussels in February 1922 under the patronage of

King Albert. Its objective was to exchange medical, surgical, and sanitary lessons

learned during the war and in reconstruction. To facilitate this exchange, it sponsored a journal, the Bulletin International, published monthly with side-by-side

English and French texts as a supplement to the Annales Belges de Médecine

Militaire. Articles about pertinent developments in participating countries, including the United States, appeared in the bulletin from time to time.

More than thirty nations sent delegates to the first meeting, including twenty

that sent official representatives from the medical departments of their army or

navy. The United States had a representative, Commodore William Seaman

Bainbridge, a reserve Navy doctor who had been authorized by the government to

attend, but at his own expense. Bainbridge was made a member of the executive

committee that was responsible for arrangements for future congresses, and the

U.S. Naval Medical Bulletin devoted an entire issue to his report of the proceedings.83 At this first meeting, Dr. Uzac and Dr. Vincent of the French ministry of

war discussed the evacuation of the wounded and noted that the use of air ambulances, or sanitary airships, already initiated on a limited scale in some theaters of

war seemed to promise good results for the evacuation of wounded men under the

best possible conditions of security, rapidity, and comfort.84

Bainbridge was also a delegate to the second congress and to meetings of the

executive committee held in Rome in May and June of 1923. Speakers, who once

24

A History of Aeromedical Evacuation in the U.S. Air Force

A Douglas C–1, Air Service aircraft modified to accomodate patients.
again included Dr. Uzac of France, discussed medical and organizational aspects

of evacuation by various means, including sanitary airships.85 These discussions

were highly relevant to issues regarding the selection and preparation of the

wounded for evacuation by air, which emerged as the performance of transport

aircraft increased and their use to evacuate the sick and injured became more common.

The executive committee of the congress also sponsored the First

International Congress of Medical Aviation which met in Paris during May 1929.

Here too, discussions dealt with some very pertinent medical, legal, and practical

questions, although Major De Block, the rapporteur, expressed regret that none of

the major powers, including the United States, had seen fit to provide information

about their experiences with sanitary aviation in their colonial experiences. This

definitely restricted the value of the conclusions reached and presented, he

believed, only a partial impression of sanitary aviation during 1929.

The congress did discuss materiel and personnel aspects of aeromedical evacuation, including prospects for pressurized aircraft, the safety of transported

patients from fire and other aviation hazards, practical difficulties of using commercial aircraft as air ambulances, and the advantages of using autogyros for landing in a densely populated country.86

What De Block considered the big question—medical-surgical indications

for transport by air—was barely touched upon. He expressed some of his own

observations and cited the work of a physician who was addressing this issue by

subjecting guinea pigs with various kinds of wounds to reduced pressure in a caisson. The experimenter’s conclusion was that all superficial wounds and wounds

of the extremities were perfectly suitable for air transport, but he warned that pen25

The History of Aeromedical Evacuation in the USAF

A Fokker T–2, Air Service aircraft modified to accomodate patients.
etrating wounds of the abdomen, chest, or stomach required extreme caution.

Obviously shaped by the war just past, De Block’s evaluation of these warnings

was that they were fine for peacetime, but in merciless war he would rather take

deliberate risks than wait for the problematic arrival of essential help.

Under the rubric of “personnel,” the congress dealt with the question of keeping aviators and medical personnel of sanitary aviation wholly separate from the

operational forces. Pointing out inconsistencies rooted in the prevailing imperialism of the major European powers, the session rapporteur noted, apropos of the

utilization of the French air force against insurgents in Morocco, that

The conditions in Morocco permitted the employment of the

Air Service on bombing duty during the morning and transporting wounded in the evenings, reconnoitering under the illusory protection of the Geneva Cross. It must be different in civilized war.

87

The congress also commented upon three decisions made by the Twentieth

Conference of the International Red Cross in 1925 regarding the immunity of

medical aviation. These repeated the need to extend the 1906 Geneva Convention

protections for mobile sanitary formations to materiel and personnel employed

exclusively in transporting or treating the wounded by air; reaffirmed the loss of

these protections if the formations or personnel committed hostile acts against the

enemy; and repudiating the innocence of the prewar period, declared that sanitary

aircraft should not be employed in searching for the wounded on the battlefield.

In a somewhat dry aside, De Block agreed, noting that whereas in 1912 sanitary

aircraft had been viewed as an instrument to be used in the evening after a battle

to locate the wounded who were left, perhaps in small groups, or nests, battles

now had no evenings, and “nests of wounded” existed only in the imagination of

“correspondents in the Balkans.”88

De Block disagreed with a consensus of the Red Cross conference that sanitary aircraft should be allowed to fly with impunity over enemy lines; as the Red

Cross representatives had put it, “the carrying of wounded comes before anything.” De Block commented that the Red Cross should not be overindulged

because the enemy could not reasonably be expected to give sanitary aircraft permission to survey his lines and positions. For this reason, De Block stated his own

preference for forgoing immunity for sanitary aircraft in the forward area of an

army in the field, while admitting that no one, in Paris or elsewhere, agreed with

him.89

The International Committee of the Red Cross (ICRC) was active during the

1920s, particularly regarding proposals to extend the protections of the Geneva

Convention of 1906 to air ambulances, an objective that was finally achieved in

the Geneva Convention of 1929 in line with the decisions of the Twentieth

Conference. The ICRC journal, the Revue Internationale de la Croix-Rouge, published numerous articles about developments in sanitary aviation and the relevant

26

A History of Aeromedical Evacuation in the U.S. Air Force
work of the various ICRC subcommittees.90 The Monthly Bulletin of the League

of Red Cross Societies, published in Paris in English, also had frequent short articles about sanitary aviation, including notices of periodic meetings of the

International Air Ambulance Congress which began in Paris in 1929, and similar

organizations such as the International Study Commission on Air Ambulance

Services formed in 1934.91

The ICRC was also involved with sanitary aviation in other ways. One of its

subcommittees, the Permanent International Commission of Standardization of

Field Medical Equipment, worked with the Executive Committee of the Congress

of Military Medicine and Pharmacy to standardize patient litters for aircraft and

other conveyances in which litters might be carried.

The United States contributed to this work, but its views on sanitary aviation

do not seem to have been accorded much weight, probably because the development of aeromedical evacuation in the United States during the 1920s and 1930s

was so limited compared with that developed by the United States’ European

counterparts. This was rather graphically demonstrated in 1930 when the ICRC

standardization subcommittee chairman rather summarily dismissed the opinion

of the U.S. Army surgeon general, General Ireland, that an internationally standardized litter for carrying patients in aircraft was not needed, deeming Ireland’s

opinion insufficient against the collective judgment of the Commission on

Standardization.92 Whatever the respective merits of the two cases, certainly

underlying the European attitude toward any U.S. position was the fact that the

European powers had gained far more experience with aeromedical evacuation

since the war than the United States had.

For the French, the utility of air ambulances outside metropolitan France had

been demonstrated even before World War I ended. They had proved particularly

useful in Morocco, where France fought a running war for a number of years with

relatively small forces against insurgents in the rugged countryside, far from the

coastal cities under French control. The French experienced the difficulties of

evacuating wounded by land transportation in western Morocco under hostile

conditions during a campaign from October 1911 to April 1912. During this period, an evacuation of 53 wounded from the interior to Casablanca, a distance of

some 125 miles, had taken nine days, including a two-day rest stop in Rabat.93 In

September 1918, 15 of some 60 soldiers wounded during a battle in southern

Morocco were evacuated in an hour and ten minutes in tactical aircraft flying

some 68 miles over country controlled by the insurgents. In January 1919, a

French general who had been seriously wounded during fighting in the Sahara

was saved through medical aviation. As one of the attending French physicians

described it, a surgeon was flown more than 185 miles over the Atlas Mountains

to administer to the general within hours. Because the available medical facilities

proved inadequate for the general’s effective treatment, he was evacuated by a tactical aircraft in less than an hour to a hospital center, where he was treated and

later recovered. Had it been necessary to move him by surface means to receive

27

The History of Aeromedical Evacuation in the USAF
the proper care, it would have meant a journey of nine days, from which he probably would not have recovered.94

By 1921, Dr. Chassaing’s air ambulances began to arrive in North Africa and

the Middle East, where similar difficulties of terrain and hostilities generated

combat and casualties. Both tactical aircraft and air ambulances were used extensively to evacuate casualties from Morocco during the Riffian war in the 1920s

and from Syria during the same period. By the end of 1925, almost 3,000 cases

had been evacuated by aircraft, without accident, and air ambulances were stationed in Indochina and French West Africa.95 By the early 1930s, a senior French

medical officer could hail sanitary aviation as part of the normal sanitary equipment of North Africa and all areas outside metropolitan France, without which it

was inconceivable that the French Sanitary Service could perform its mission.96

Notably, at the twelfth aeronautical exhibition held in Paris in December 1930,

aircraft manufacturers showed seven different aircraft designed to be used as air

ambulances. Among them was a trimotor made by the Société Provençale de

Constructions Aéronautiques that had many specialized features, including a

table, chair, and cabinet in which to store medicines and equipment, a washbasin,

a cooling and heating system, and large doors through which sick and wounded

could be loaded easily. It was advertised as having the ability to fly at an altitude

approaching 3,300 feet with one of its three engines inoperative.97

The experience of Great Britain in the Middle East and India was similar. The

British had experimented with aircraft to carry its wounded prior to 1914, but the

official position of the War Office against evacuating the wounded by air precluded any serious attempt during the war to develop an aeromedical evacuation

capability. In 1913, Lt. Col. J. D. F. Donegan of the Royal Army Medical Corps

conducted experiments with a biplane amphibian aircraft that had been fitted as a

flying operating room and was capable of evacuating two wounded men. Aware

of Dr. Reymond’s work, Donegan apparently approached the War Office with

some sort of air ambulance proposal before the outbreak of war, but his proposal

was not accepted.98

As with air evacuations conducted by French pilots operating with the

Serbian army in 1915, the first British evacuation of a wounded soldier came in

1916 in response to both a medical and a tactical necessity. During the British

campaign against the Turks in the Sinai desert, a trooper of the Imperial Camel

Corps had his leg shattered by a bullet fired by armed Bedouins. He was apparently the only casualty because, although an attack had been planned on the

Turkish garrison, its occupants surrendered without a fight. The local medical

officer prevailed on a pilot from the Royal Flying Corps to fly the trooper in a tactical airplane to a casualty-receiving station some 45 minutes away by air, versus

the 21⁄2- to 3-day trip that would have been required by camel and rail.

British tactical aircraft were also used during the war to fly surgeons to areas

where their skills were needed, but it was not until after the war that aeromedical

evacuation was officially undertaken. As Billy Mitchell and his inspection team

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A History of Aeromedical Evacuation in the U.S. Air Force
reported, the British began to plan for the use of transports as air ambulances in

the early 1920s. After the British experienced the same difficulties in their areas

of colonial interest that the French had experienced in theirs, the British began

almost immediately to use converted tactical aircraft as air ambulances. During

the Zed Expedition in British Somaliland against the rebel Dervishes, a DH–9 was

fitted out as an air ambulance and used extensively to evacuate casualties from the

interior to hospital care at British bases.99 An RE8 reconnaissance aircraft was also

used as an air ambulance in 1920 during a British expedition on the Syrian-Iraqi

border. Surrounded in a small town, the British evacuated a British officer suffering from a bullet wound in his liver the 200 miles to Baghdad in the RE8 in a

flight lasting more than three hours.100

Air evacuation became a standard British practice in the Middle East, particularly in Iraq where the British mandate faced stiff resistance during the 1920s. In

many respects, the use of aircraft to evacuate casualties seems like a wholly natural counterpart to the policy of air control that the British adopted after World

War I. Their objective at the time was to coerce, at reasonable cost in money and

lives, the acceptance of British authority over the former Turkish territories that

Britain had acquired as League of Nations mandates. Air control mitigated the difficulties and lowered the costs of maintaining expensive ground forces with which

to coerce recalcitrant tribes into accepting British authority and the authority of

the Hashemite king Faisal I, whom they had installed in Baghdad.101 The Royal

Air Force made use of converted tactical aircraft until 1923 when the new convertible transports that Mitchell and his party described were deployed. Vickers

Vernon transports fitted as air ambulances were used extensively thereafter with

considerable success. The Royal Air Force medical officer who described the

29

The History of Aeromedical Evacuation in the USAF

DH–9 Air Ambulance with Z Force in British Somaliland, 1919.
whole effort, after making recommendations for improvements in both air ambulances and the evacuation system as a whole, noted that the use of the Vickers

Vernon troop carriers configured as air ambulances, though invaluable, was “still

not clear under the Geneva Convention.”102

Conclusion

As what might be called the decade of the dictators, which ended in World

War II, was about to begin, aeromedical evacuation—or sanitary aviation, its

broad European synonym—was flourishing among the European nations. In

Europe, events of the 1930s would pointedly raise issues under international law,

and conflicting military requirements for the operational forces and their supporting medical establishments would begin to be seen more clearly. In the United

States—in spite of the continuing efforts by the Air Corps medical division and

others to move the Army beyond its narrow focus on crash rescue and other air

ambulance functions by pointing out new opportunities to eliminate elements of

the chain of evacuation by literally moving over them—little was accomplished.103

The appeals by the surgeon general in his annual reports to the War Department

requesting a replacement air ambulance as accidents eliminated the Cox-Klemins

and use began to erode other modest capabilities found in aircraft like the Douglas

C–1s speak loudly about the priorities of the Army and the War Department and

the continuing fixation of those agencies with the lessons of World War I. It would

take extraordinary leadership, a growing perceptible threat, and the beginnings of

rearmament to change the situation in the 1930s.

30

A History of Aeromedical Evacuation in the U.S. Air Force
Chapter 2

DAVID GRANT AND THE EMERGENCE OF

ORGANIZED AEROMEDICAL EVACUATION IN

THE UNITED STATES ARMY

Advances in aeronautics achieved in the 1930s led to aircraft with markedly

greater capability. Transport aircraft could travel longer distances and carry more

than the handful of litter patients associated with the air ambulances still found on

most Army airfields as the decade began. Over the course of the 1930s, rudimentary aeromedical evacuation systems were being developed in many European

countries, including the Soviet Union. These systems used a variety of aircraft as

air ambulances to meet peacetime medical emergencies, and the Spanish Civil

War and Russo-Finnish War showed that aeromedical evacuation could be useful

not only in civilized warfare but in colonial conflicts as well. The Luftwaffe’s

evacuation flights to Germany were particularly valuable in the development of

an aeromedical evacuation doctrine because they provided the U.S. Army’s proponents of transporting patients by air with empirical data on the effects of

aeromedical evacuation on patients suffering different kinds of wounds and illnesses. Such data permitted validation of the theoretical criteria for patient selection derived from the expanding knowledge about the physiological effects of flying on the human body. The Aeromedical Research Laboratory established in

1934 symbolized the search for increased knowledge and contributed to its attainment.

Information on aeromedical evacuations outside the United States was widely available to the Army’s medical professionals. Journals like The Military

Surgeon contained articles by U.S. proponents who came chiefly from the ranks

of the medical section of the Air Corps. However, the direct experience of the

31

The History of Aeromedical Evacuation in the USAF
Army Medical Department and the surgeon general with the transport of patients

by aircraft was limited essentially to emergency medicine and further constrained

by limited budgets. Consequently, the Army’s medical hierarchy tended to view

aeromedical evacuation as a potential supplement to the chain of evacuation in the

context of war. The medical department’s evacuation planning was in accord with

organizational and doctrinal changes to the Letterman scheme that the Army had

made after World War I. These changes were based on a model of essentially static conflict using casualty rates drawn from those the service experienced on the

western front, though the model’s limitation with regard to mobile warfare was

acknowledged.

Perceptions of aeromedical evacuation by the surgeon general and his planners were also influenced by strains emerging within the Army between its airmen

and the General Staff that were reflected within the Army Medical Department.

The maturation of aviation medicine as a separate body of specialized knowledge,

as well as the development of doctrine at the Air Corps Tactical School (ACTS)

that emphasized an autonomous strategic mission for the Air Corps, contributed

to a growing corporate sense among flight surgeons which they shared with the

Army’s fliers. More importantly, it helped deepen a cleavage within the Army

Medical Department that had existed to at least some degree since World War I.

The difference was basically between officers in the department who were flight

surgeons and had essentially cast their lot with the AAF and the more traditionally minded Army surgeons who identified with the surgeon general and embraced

therapeutic rather than preventive medicine. At least some of the latter group

revealed a rather jaundiced view of both airplanes and aviators, as did some members of the prewar General Staff.

David Norval Walker Grant was instrumental in overcoming these constraints

and on the eve of war successfully secured War Department recognition of a larger role for aeromedical evacuation. A member of the Army Medical Department

since 1916, Grant became a flight surgeon only in 1931. Assignment immediately following graduation to Randolph Field, Texas, the newly opened center for Air

Corps training, and in 1937 becoming the first flight surgeon to attend the ACTS

informed Grant of the problems faced by the Army’s aviators and flight surgeons.

It also brought him into contact with the spirited and definitely separatist group of

young Air Corps pilots who would emerge as the wartime leaders of the AAF.

Assigned to the medical section of the Office of the Chief of the Air Corps in

1939, Grant’s institutional and personal loyalty won the respect of Hap Arnold,

chief of the Air Corps and soon to be AAF commanding general. Having Arnold’s

confidence was a major asset in Grant’s success in two important endeavors: first,

in evading an effort by the surgeon general to end the autonomous status that the

Air Corps medical department had essentially realized, and second, in working

with the surgeon general’s office and the General Headquarters (GHQ) surgeon to

develop and promulgate an official table of organization (T/O) for aeromedical

evacuation units. The status of aeromedical evacuation in the U.S. Army when the

32

A History of Aeromedical Evacuation in the U.S. Air Force
Japanese attacked Pearl Harbor was, therefore, basically twofold: an official Army

recognition of the value of evacuating patients by aircraft, as exemplified by the

publication of a War Department T/O; and an implicit commitment to use

aeromedical evacuation units in ways yet to be determined, should war come.

The Evolution of Air Ambulance Requirements

in the United States

Albert Truby, director of the Air Service medical department from 1919 to

1923, had envisioned air ambulances as fulfilling different functions related to the

varied medical conditions of individuals being transported.1 Victims of aircraft

accidents requiring emergency first aid and movement to the nearest medical

facility required aircraft capable of taking off and landing in short distances on

unprepared ground. The transport of patients whose conditions were stable but

who required definitive treatment at one of the Army’s general hospitals required

aircraft with different characteristics. Because the Army had only a few such hospitals and they were typically some distance from the training bases, aircraft used

for this type of aeromedical evacuation required features to permit patient comfort and space for attending medical personnel. Although the War Department had

accepted Truby’s concept, funding constraints and the more obvious need for

effective crash rescue vehicles led during the 1920s to an emphasis on air ambulances. As aeronautical engineering advanced rapidly during the same decade,

development of larger, longer-range transport aircraft indicated that they might be

considered for use as air ambulances in the narrow sense as well as for patient

transport as envisioned by Truby.

33

Emergence of Organized Aeromedical Evacuation

The Cox-Klemin aircraft, designed for and dedicated to aeromedical evacuation.
Procurement of the two Cox-Klemin airplanes specifically designed for and

dedicated to aeromedical evacuation had been one result of the obvious need to

replace the hodgepodge of modified trainers and tactical aircraft used for crash

rescue that had proliferated independently at Air Service flying training fields during World War I. As a way of providing additional ambulance capability and following the British lead, the Air Corps directed that all transport aircraft purchased

after 1924 have brackets installed to permit the installation of litters for carrying

patients in emergencies.2

The Douglas C–1 transports procured in the late 1920s incorporated attachments on the floor and walls of the cabin that allowed them to be converted to litter carriers, and their assignment to various Air Corps stations together with the

Cox-Klemins provided a distributed air ambulance capability that was widely

used.3 One of the Cox-Klemin aircraft, based at Kelly Field, had carried twentysix patients in its first six months of service in 1926, and it responded to crashes

and other emergencies within a radius of several hundred miles of San Antonio.

In April 1927 this aircraft evacuated tornado victims from Rocksprings, Texas.

Also during 1927, the C–1 stationed at March Field made numerous flights carrying emergency patients to Army general hospitals in San Diego and San

Francisco.4 Air ambulances were also used to good effect in Central America, in

Panama, where C–1s stationed at France Field flew mercy missions transporting

both military and civilian patients from remote locations in the jungle to Albrook

and France airfields, and in Nicaragua during the U.S. Marine operation against

the Sandinistas. In Nicaragua, using an improvised air ambulance, eighteen

wounded marines were flown to safety in ten flights from a besieged detachment

in January 1928.5

As the Cox-Klemins began to wear out, their imminent demise helped determine what requirements should be given priority in their replacement. Designed

primarily for the purpose of rescuing downed fliers, the Cox-Klemins had relatively short ranges and were unique in their ability to land and take off from

extremely short and unprepared fields. Reserving them for or dedicating them to

crash rescue or similar emergencies was a decision essentially inherent in their

design and acquisition. As the Air Corps began to procure commercial transports

having longer range and greater lifting capability, which became increasingly useful for carrying passengers or cargo in logistic support of Air Corps stations, new

questions arose regarding their use and the wisdom of dedicating some aircraft

exclusively to aeromedical evacuation.

The issue of which approach to adopt—whether to design special aircraft and

dedicate them to perform as air ambulances, or whether to use commercially developed transport aircraft fitted with attachments permitting them to be converted into

air ambulances in emergencies—was decided in 1930 by Maj. Gen. James E.

Fechet, chief of the Air Corps. Despite the urging of his chief flight surgeon, Lt.

Col. L. M. Hathaway, that at least a few special hospital planes be constructed to

continue further development of the type, particularly in the area of patient com34

A History of Aeromedical Evacuation in the U.S. Air Force
fort, Fechet opted for using transports for air ambulance work.6 He may have been

partially influenced by Hathaway’s enthusiastic comment that a temporarily modified Ford Trimotor transport used during annual field exercises at Sacramento,

California, in the spring of 1930 represented “a long forward step toward development of the ultimate air ambulance.”7 The Air Corps chief directed that suitable

installations be developed for converting transports for aeromedical evacuation,

and his successor, Benjamin Foulois, ratified the decision in 1933.

Responding to a request from the Army adjutant general for a description of

the military characteristics desired for future air ambulances, Foulois’s deputy,

Oscar Westover, submitted a statement of military characteristics that essentially

duplicated the characteristics submitted for a future cargo airplane that the Air

Corps also requested. The air ambulance was to be a single-engine or multiengine

land plane with a maximum speed of 150 mph, a service ceiling of 16,000 feet,

and a range of 500 miles or more at a cruising speed of 125 mph. Its mission was

to evacuate the sick and wounded from airfields in a theater of operations to the

rear areas while carrying a pilot, a medical attendant, and either ten seated or six

litter patients.8

Because, as the adjutant general noted, cargo plane characteristics had

already been approved by the War Department, no separate air ambulance

approval was made. The surgeon general acknowledged that the large aircraft

would provide a practical air ambulance for emergencies, but he reaffirmed the

need for a new crash rescue type. Speaking for the surgeon general, his assistant

Lt. Col. T. E. Darby asserted the urgent need for about four small rescue type air

vehicles capable of transporting a pilot, medical attendant, and two litter patients

and of landing and taking off in a minimum distance on rough terrain, all of which

in effect duplicated the Cox-Klemin’s capabilities.9

Statistics on flying accidents continued to reflect the dangerous nature of flying, particularly during flight training, bolstering the surgeon general’s view. In

FY 1931, the Air Corps suffered 456 accidents in which 26 people died and 75

were injured. The next fiscal year had an even higher casualty rate: 50 were killed

and 89 injured in 423 accidents. Because approximately 1,900 Air Corps regular

and reserve personnel, including pilot trainees, were engaged in flying operations,

these accident and death rates are quite high.10

Consistent with its new emphasis on converting transport aircraft for aeromedical evacuation, the Air Corps had procured a specially modified Fokker transport

in 1930. Its capabilities and characteristics were quite close to those described as

ideal for future air ambulances and, three years later, for cargo planes.11 This aircraft, when used as an air ambulance, had storage facilities for medical equipment.

It performed effectively in the first large-scale Air Corps maneuver of 1931, which

was also the first maneuver that included the medical division. However the

Fokker proved unsuitable for crash rescue work, and this led the flight surgeon,

who was serving as surgeon for the maneuver, to review the surgeon general’s

response to the 1933 Air Corps statement of air ambulance characteristics. He rec35

Emergence of Organized Aeromedical Evacuation
ommend that two types of air ambulances be used in future maneuvers: one would

be used to transport patients; the other would be used for crash rescue work.12

Some members of the Army medical community had begun to stress the

potential value of aeromedical evacuation in war. These individuals viewed the

development of advanced transport aircraft as providing more than just a way to

move patients quickly and efficiently in an emergency. Army medical officers

began to write and lecture about using aeromedical evacuation to meet wartime

requirements, noting that this form of evacuation might well be the method of

choice in any future conflict. Two seminal articles appeared in The Military

Surgeon, which required the surgeon general’s approval for their publication.

Each author pointed to the commercial transport as a basis for a new system of

aeromedical evacuation that would materially improve the wartime treatment of

casualties. The article by flight surgeon Capt. Robert K. Simpson appeared in

January 1929; the other by Lt. Col. Darby appeared in August 1932.13 Both

reached wider professional audiences through other media. Simpson’s article

appeared, unattributed, in The Army Medical Bulletin in September 1931; Darby’s

was presented as a lecture to the students at the ACTS in January 1932.14

These two articles are quite similar in concept and approach; they contain the

first truly comprehensive statements of how an aeromedical system for the U.S.

Army could be organized and operated. The authors identify many of the tactical,

strategic, and logistic arguments for such a system.15 Their assumptions are also

useful for revealing their frameworks of reference. To the degree that the leadership of the Army Medical Department viewed an aeromedical system similarly,

and evidence shows that they did, serious problems could arise if their views

turned out to be inconsistent with the realities of the coming global conflict. The

medical department could find itself having to reorder its evacuation planning in

unanticipated ways and thus be forced into using aeromedical evacuation in ways

that its members might find difficult to deal with.

Simpson and Darby essentially describe the same advantages and offer generally the same prescriptions for organizing an evacuation system to supplement

or replace the Army’s then-current Letterman-based system, which was keyed to

dividing a theater of operations into a combat zone and a communications zone

(COMZ). The COMZ adjoined the rear area of the combat zone and was under

separate command authority, although both zones came under jurisdiction of the

theater commander. Simpson and Darby both saw evacuation by air as offering a

significant advantage over the Army’s ground-based system because air ambulances made it possible for the seriously wounded to receive much earlier definitive treatment. The generally agreed-upon window during World War I for the

most effective surgery was six to eight hours post-incident, and greater aircraft

speed, a lack of obstacles to their flight, and elimination of steps in the Army evacuation system were used to achieve this time frame.

In the Army system, individuals whose wounds were serious enough to justify their evacuation from the combat zone to the COMZ passed through aid sta36

A History of Aeromedical Evacuation in the U.S. Air Force
tions, hospital stations, and evacuation hospitals on their way to general hospitals

for definitive treatment, the whole system being staffed by medical personnel of

the medical regiment attached to each infantry division. The regiment comprised

collecting, clearing, and ambulance companies manned with personnel possessing

medical skills to provide first aid and interim treatment and the personnel and

equipment needed to transport patients along the evacuation chain as far as their

condition dictated. Included along the way might well be a stop at a mobile surgical hospital for the unevacuables—those so seriously wounded that they could

not yet stand the rigors of being moved to a general hospital.

For those who could be moved, the journey would be continued by hospital

train or possibly hospital ship. Where depended on whether or not mobile forces

or forces fighting on a fixed front were being supported. Simpson and Darby postulated removing patients from points close to the front lines in the combat zone

and transporting them rapidly by air to general hospitals in the COMZ, thus eliminating several links in the chain of patient transit toward the rear areas. The resultant compression of time when moving and processing casualties would mean that

a wounded patient could receive definitive care in a general hospital in the COMZ

sooner than if he had been subjected to being processed through the Army’s normal ground-based evacuation system.

The reduced stress experienced by a patient transported by air compared to

motor ambulance or hospital train would mean that previously unevacuable

wounded, which Simpson identified as the most seriously hurt, especially those

with wounds of the head, neck, or abdomen and those with fractures of the long

bones, the femur in particular, could be moved to general hospitals for definitive

surgery. This additional benefit was important because it would reduce the

prospect of having to undergo surgery twice: once at a mobile surgical hospital, at

which unevacuables were given interim treatment, and later, definitively, at a general hospital.

Medical personnel could be conserved by eliminating links such as the

mobile surgical hospitals, which would allow them to be reassigned from hospital facilities in the combat zone to general hospitals in the COMZ. Because casualty rates were unaffected, the total number of patients to be treated would remain

the same. The aeromedical system would make it possible to redistribute medical

personnel more efficiently and make it possible to perform surgery more quickly

and under better conditions than those available in the field.

Darby, who provided a bit more specificity in his article than Simpson did, calculated that a practicable aeromedical evacuation service could probably reduce

the Army medical service in the combat zone by ten surgical hospitals, eight evacuation hospitals, and two army medical regiments. He also calculated that, because

air ambulances returning to the forward areas could carry medical supplies,

aeromedical evacuation could reduce by approximately one-third the amount of

medical supplies maintained in the army medical depot. Other savings would also

be possible, such as reducing the number of hospital trains in the COMZ.

37

Emergence of Organized Aeromedical Evacuation
Darby and Simpson both commented upon how air ambulances would ease

pressures on ground lines of communication (LOCs), and they described the proposed aeromedical units in some detail. They addressed the number of aircraft in

a flight and the number of flights in a squadron, their assumed litter and ambulatory patient carrying capacity, and the command echelon at which control of the

air ambulance units should be exercised.16 Although Darby believed that the great

mobility of air ambulance units dictated that they be centrally controlled as part

of GHQ aviation and operated under the direction of the GHQ surgeon, Simpson

proposed that such units be assigned to ground commanders, for instance, assigning an air ambulance squadron to each infantry division. Both authors explicitly

stated that aircraft used as air ambulances would have to be designated for their

protection in accordance with the prescribed 1929 Geneva Convention.

Neither author discussed medical regulating criteria—parameters for selecting

or rejecting patients for evacuation—with respect to the physiological stresses

induced by the lower oxygen level and reduced atmospheric pressure encountered

during flight. Their solution to the problem of securing aircraft and crews to equip

their proposed wartime aeromedical evacuation systems foreshadowed the future

Civil Reserve Air Fleet (CRAF) arrangements, whereby airlines in return for subsidies accept modifications to their aircraft to make them suitable for military use.

Both men recommended the wartime mobilization of civilian commercial aircraft

and their crews and their conversion into air ambulances.17 An Air Corps officer,

whose favorable commentary was published with Simpson’s article, anticipated the

CRAF even more strongly by suggesting that aircraft manufacturers be advised of

this prospective use so they could facilitate a future conversion by taking appropriate design actions like increasing the size of loading doors and including devices

that would permit an immediate installation of litters.18

Although quite prescient about future aeromedical evacuation in general,

Darby and Simpson made several assumptions that have other implications. The

framework for their analysis was based on the Army’s experience on the western

front in World War I. The casualty rates they used to calculate the possible number

of necessary aeromedical evacuation missions therefore might not be relevant for

the type of war the nation’s military might fight in the future or, more importantly,

for the size of the aeromedical evacuation capability required because, in effect, the

rates were postulated on a war of fixed position dominated by frontal attacks

against strong defensive lines, a tactical scenario that tends to generate large numbers of casualties.19 On the basis of warfare of fixed position, as Simpson put it,

with the enemy having the capability, as it did in France, to shell possible landing

fields with artillery, he and Darby assumed that air ambulances would not be able

to operate any closer to the front lines than the vicinity of the station hospitals,

approximately five to six miles behind the front. Still obviously thinking of France,

neither man apparently considered this a major problem because they assumed that

roads in the combat zone would allow motor ambulances to bring in the seriously

wounded from the collecting stations to evacuation airfields.

38

A History of Aeromedical Evacuation in the U.S. Air Force
Lt. Col. G. P. Lawrence immediately challenged Darby’s assumption that air

evacuation was constrained to the rear areas of the combat zone. This reserve officer argued in the pages of The Military Surgeon that restricting air evacuation to

the rear areas was an unnecessary abdication of that part of the medical department’s responsibility to evacuate casualties from the combat area as rapidly and

safely as possible. The solution Lawrence offered was the autogyro, an unconventional helicopter-type aircraft first brought to the United States in 1928. The

autogyro could descend essentially vertically to points immediately behind the

front lines and rise again with, depending on the wind, a very short or virtually no

takeoff roll.20 The seriously wounded could then be flown directly to general hospitals, thus reducing the various elements in the chain of evacuation as both Darby

and Simpson envisioned.

Another medical department surgeon had also recently written in The

Military Surgeon about the possible use of autogyros as air ambulances, and the

whole minidebate indicated considerable intellectual ferment within the Army

Medical Department.21 The concept proved to be impractical for most of the 1930s

because, as Lt. Col. Louis H. Bauer, a former SAM commandant, ruefully lamented in a paper read to the Association of Military Surgeons in the autumn of 1929,

in spite of the vast strides that the United States had achieved in aeronautics it was

hopelessly behind Europe in the development and use of the airplane ambulance.22

In fact, progress would remain static until events in Europe generated interest in

U.S. rearmament and until lessons learned from the European use of aeromedical

evacuation might be applied to improve medical support for the U.S. Army.

Factors Affecting the Development of Aeromedical Evacuation

in the 1930s

The lack of material progress stemmed largely from the lack of money allocated to the War Department during the Great Depression, which made the Air Corps

unwilling to expend funds on new air ambulance aircraft when it needed to modernize its combat fleet. This continued to be true during the period after September

1939 when the Air Corps and the Army as a whole began to expand. This greater

priority on modernization was coupled with the growing dependence of the Air

Corps on air transport to support training and other operational activities and its consequent reluctance to divert transports from their primary function. The surgeon

general’s annual reports to the Secretary of War for 1930 through 1941 repeatedly

contain statements that no additional ambulance planes were procured during the

preceding year although they were urgently needed.23 In 1932, the chief of staff of

the field service section at Wright Field even attempted unsuccessfully to reacquire

four transports that had been converted into air ambulances because they could carry

aircraft engines more easily than could the other available cargo planes.24

Another factor was clearly at work with regard to the lack of push within the

Army for a more expansive view of the military value of aeromedical evacuation.

39

Emergence of Organized Aeromedical Evacuation
It is difficult to document or assess its scope and what specific effect it might have

had on the development of aeromedical evacuation during this period, but evidence suggests that a strain of skepticism, if not hostility toward aviation and aviators, existed among some senior members of the army General Staff and the

Army’s Medical Department. Presumably intensified by the Air Corps leaders’

open struggle with the General Staff during the 1930s for recognition of the value

of an air force—an offensive action centrally directed—this critical attitude

undoubtedly colored the opinions of military surgeons toward their colleagues

involved in aviation medicine. It would be a visible factor in the evolution of

aeromedical evacuation when the United States returned to war.

This skeptical attitude had a lengthy pedigree. In 1917 the headquarters of the

American Expeditionary Force (AEF) stifled Colonel Lyster’s bid for autonomy

at the behest of the chief surgeon of the AEF’s LOC. This might be explicable as

a bid to preserve sound organizational principles, but the hostility that Gen. John

Joseph Pershing and his senior staff had shown toward giving aviators with the

AEF in France extra pay for flying to compensate for the activity’s inherent danger reflects a lack of understanding about the very nature of flying.25

General Mitchell’s challenge to the General Staff, for which the former head

of the Air Service had been court-martialed in 1925, won no friends in the Army

hierarchy either for him or for the Army’s other aviators. The most interesting

reflection of skepticism by the Army’s brass and seemingly by the medical department is to be found in a lengthy review of a book published in 1927 by the pseudonymous Briton, “Neon.” Pershing’s former chief of staff of the AEF and his

deputy chief of staff after the war Maj. Gen. James G. Harbord reviewed the book,

The Great Delusion (A Study of Aircraft in Peace and War), for The United States

Naval Institute Proceedings, the U.S. Navy’s professional journal. Harbord presented an extraordinarily long review.26

The book and Harbord’s own lengthy approbatory text are both unrelievedly

negative toward the idea that either military or commercial aviation has anything

of value to contribute to modern civil society or warfare. Harbord accuses the

press of complicity in helping convey an erroneous picture of aviation’s progress

by allowing itself to be manipulated “by every artifice known to propaganda,” and

he singles out for condemnation aviators, who, while soldiers and sailors are still

studying the lessons of World War I, “make claims in peace far out of proportion

to their accomplishments and already assert the obsolescence of armies and

navies.”27

Neon’s negativism, which Harbord vigorously embraced, was rooted in two

things. First, and primary, was Neon’s assertion that the aircraft engine, now

improved continuously for thirty years, had reached the upper limit of its development and, because an aircraft’s engine was its very soul, there could be “no real

scope for generally effective improvement in performance.” Second was a lengthy

list of aviation’s purported inadequacies in peace and war to date. While acknowledging the gallantry and heroism of someone like Charles Lindbergh, Harbord

40

A History of Aeromedical Evacuation in the U.S. Air Force
agreed with Neon’s dire analysis. For example, Neon asserted that after fourteen

years of an exhaustive search for efficiency, carrying a pound of freight one mile

in an airplane cost about as much as carrying one ton one mile in a railroad train.

To Neon, commercial aviation was “inherently unable to operate on a profit-making basis.” He made several other comparisons purporting to show the great disparity in cost between commercial transport by aircraft and various surface

modes, including tramp steamers and passenger liners.28

With regard to his own area of direct experience—war—Harbord approvingly quoted Neon’s propositions: “1. that aerial reconnaissance is unreliable, 2. that

aerial combats in themselves have no influence upon the advance of the enemy or

the ultimate result of the war, 3. that bombing is inaccurate and therefore can only

be indiscriminate and against non-military population (including women and children), offending civilized opinion and international feeling if not international

law, [and] 4. that such bombing is inherently expensive, is utterly ineffective so

far as winning the war is concerned, and that air operations can only be carried on

at enormous and disproportionate cost.”29

Harbord concluded his review by recommending that everyone with a role or

interest in national defense should read Neon’s book and that every national leg41

Emergence of Organized Aeromedical Evacuation

Maj. Gen. James G.

Harbord
islator should study it to understand the excess to which propaganda for aviation

had led the country. He was clear in his own mind that air service “in proper proportion” would always be an auxiliary arm for both the army and the navy, albeit

an unreliable one, because factors like weather were beyond man’s ability to control. That aviation would ever replace armies or navies was a “neurotic dream,”

because wars were won on land by taking and holding hostile soil, and aviators

could do neither. As far as civil aviation was concerned, Harbord expressed his

complete agreement with the idea that although a nation might choose to subsidize civil aviation for strategic reasons, it should never fool itself into believing

that civil aviation could have commercial success.30

Perhaps useful as an example of how even captains of industry sometimes

misunderstand the limits of technology—Harbord was president of the Radio

Corporation of America when he published his review—or perhaps useful as an

example of the persistent strength of institutional loyalty, The Military Surgeon

article is relevant for two reasons. The first is the fact that the reprint had to be

sanctioned by the surgeon general before its publication, which suggests that the

surgeon general agreed in considerable measure with its contents; the second is

that the one-page editorial prefacing Harbord’s review implicitly agrees with his

approbatory comments about Neon’s book and its conclusions about aviation propaganda. The editor, a retired Army surgeon, thought that if a mind as able and

acute as Harbord’s believed Neon had said something worth listening to, readers

of The Military Surgeon would probably also think the same. The editor agreed

with Harbord that a calm estimate of the present status of aviation was in order, a

need that arose not just because of the heavy loss of life among aviators trying to

emulate Lindbergh’s heroic feat, or even the lamentable death of the Association’s

friend and member, Robert Picque, who the editor characterized as the “foremost

exponent of the airplane ambulance,” but rather because of the special qualities of

medical men who it behooved

as good citizens and as a stabilizing and influential class, who

can diagnose hysteria in the mass as in the individual, to apply

the brakes when we see that the public is traveling too fast and

not in a safe direction.31

Although Neon and Harbord were both correct that aviators sought to gain

public support of their cause through well-publicized record flights, altitude and

speed firsts, and so on, they were obviously wrong about many things, notably

that aeronautical engineering had achieved its potential. The opprobrium with

which Harbord castigated aviators as a whole could not help but be carried over

to flight surgeons by at least some of their colleagues in the Army’s Medical

Department. Perhaps rooted in the fundamental difference in their approach to

military medicine, with flight surgeons oriented toward preventive measures and

the more typical Army doctor toward treatment, flight surgeons were not necessarily held in high regard. In the view of a number of their fellow military doc42

A History of Aeromedical Evacuation in the U.S. Air Force
tors, they did not do real doctoring most of the time; they did not go into the field

with troops, make rounds in hospitals, or handle routine sick calls for large numbers of the enlisted. They seemed to prefer becoming both flier and doctor and

were sometimes almost indistinguishable in their conduct from airmen, who were

regarded by some, like Harbord, as irresponsible braggarts, or worse.32

Although one should not make too much of the then-current sociology of the

Army Medical Corps, what is known suggests several reasonable questions to ask

about how the serious consideration of using aircraft to evacuate casualties in war

might have been affected. For example, why should credence be accorded to

propositions advanced by Army doctors involved with aviation medicine, an area

of medicine so far removed from the traditional concerns of military medicine,

like surgery, epidemiology, or internal medicine? If aircraft development had

indeed reached the limit of its development, what real value could aeromedical

43

Emergence of Organized Aeromedical Evacuation

Human factors in aircraft design.
evacuation contribute to medical support of the army, beyond its already demonstrated value in emergency situations, particularly crash rescue?

Another factor could well have conditioned the way flight surgeons were perceived. The fact that at least some received flight pay, particularly during the

depression years when Congress required officers to take a cut in pay, surely must

have generated some resentment against flight surgeons.33 Because funds allocated to the War Department had higher priorities than those allotted to aeromedical

evacuation, it is probable that the development of aeromedical evacuation within

the Army beyond the status of the limited emergency service it had achieved by

the early 1930s would not have occurred had it not been stimulated by outside

events. The Army Medical Department was committed to the evacuation system

that had evolved from its experience in World War I, and aeromedical evacuation

was not included as an integral part.

Quasi-official descriptions of the Army’s evacuation planning appeared during this period in the pages of The Military Surgeon. In 1924 the former First

Army surgeon, Lt. Col. T. L. Rhoads, published an exhaustive four-part piece, of

“Principles of Evacuation,” in which he discussed the possibility of a future

aeromedical evacuation capability in very positive terms. He identified the

tremendous advantage for patient care that the air service of the future could provide. By solving the problem of how to conduct the speedy transfer of nontransportables to general hospitals, it could achieve the ancillary benefit of eliminating

surgical hospitals and redistributing their personnel and equipment to perform

other functions. As a corollary, Rhoads argued that, because the practice of using

air ambulances to move seriously ill and wounded patients would likely become

common, sites selected for new general hospitals would also have to accommodate a nearby landing field.34 An article published some three years later, and

based on a comprehensive lecture on the subject of the Army’s system for casualty evacuation, makes no mention of the possible use of air ambulances.35 Nor did

a fairly extensive report on the 1935 First Army Maneuvers in The Army Medical

Bulletin include any mention or recommendation concerning evacuation by air.

Rather, the author, one of the umpires in the exercise, concluded at the end of his

lively report that “evacuation to Regular Army station hospitals over considerable

distances can be accomplished by motor ambulances without undue hardship

upon patients.” At almost the same time, Lt. Col. C. L. Beaven, surgeon of the

First Air Division (Provisional) during the 1931 Air Corps maneuvers, was making a plea in The Military Surgeon for enough air ambulances to equip the Air

Corps’ training schools and large tactical units for rescue purposes, and for familiarizing the medical department with the value of aerial transportation in evacuating battle casualties.36 The only people seriously interested in the subject of

aeromedical evacuation in the early 1930s were flight surgeons and some Air

Corps officers, including Hap Arnold.37

44

A History of Aeromedical Evacuation in the U.S. Air Force
David Grant

In 1931, David Grant, then a major in the Army Medical Corps, entered the

aeromedical milieu when he graduated from SAM at Brooks Field and qualified

as a flight surgeon. A bit older and more senior in rank than his contemporaries at

SAM, within ten years, he would be instrumental in convincing the Army to create air ambulance units.38 He completed both his undergraduate education and his

medical school requirements in five years and received his degree from the

University of Virginia in 1915. His Army career had begun with enlistment in the

Army Medical Reserve Corps, and when he was called to active duty he attended

the Army Medical School and was commissioned a first lieutenant in 1917. His

selection to attend SAM had a strong element of luck about it, but it was supported by an excellent service record that included assignments in Panama and the

U.S. Army of Occupation in Germany. In Germany, he had commanded the occupation force’s sanitary train, forerunner of the medical regiment, charged with the

evacuation and treatment of casualties. After a year in command, he was transferred to the obstetrics service at the base hospital at Coblenz.

The luck in his selection to attend SAM lay chiefly in his timing. Apparently

for the previous four or five years, Grant had thought about applying to become a

45

Emergence of Organized Aeromedical Evacuation

Maj. Gen. David N.

Grant
flight surgeon but had not done so for family reasons. In 1930, when he made his

decision, he had just been assigned as chief of the obstetrics service at the station

hospital at Fort Sam Houston, in San Antonio, Texas, which was close to Brooks

Field and SAM. A friend, Colonel Hathaway, the chief flight surgeon, provided

both encouragement and personal knowledge to the surgeon general’s personnel

section about Grant’s record and suitability. Qualifying as a flight surgeon by

graduation from SAM did not ensure service with the Air Corps, so Grant

approached Hathaway to ascertain what his chances were to being assigned to

SAM. Hathaway warned him that, although things looked promising if his present

commander could spare him for three months to attend the school, once qualified,

he might have to wait some time for service with an Air Corps unit.

Approximately thirty flight surgeons had applied ahead of him for a flight surgeon

assignment, and none were currently serving with flying organizations.

Fortunately for Grant, who applied for such an assignment immediately after

graduation from SAM, the Air Corps found itself in need of some additional flight

surgeons. Randolph Field, a completely new installation located only some fifteen

miles northeast of Fort Sam Houston, was about to open as the Air Corps’ primary flying school and would soon become the largest Air Corps training base.

Within a month of receiving his flight surgeon designation, Grant was ordered to

Randolph as both a flight surgeon and the post surgeon.39

Grant remained at Randolph for five years, when he aggressively pursued his

duties as flight surgeon, enriching the theoretical understanding of aviation medicine gained at SAM with first-hand knowledge of the physical and psychological

problems suffered by aviators. Considering his duties as post surgeon, he flew a

great deal, although he never soloed to win a pilot’s designation. He logged 159

flying hours in 204 flights from July 1932 to July 1933. This compares well with

the War Department restriction on flying time to 175 hours in FY 1933, on average, per pilot.40 It is reasonable to conclude that one useful byproduct of Grant’s

flying experience when coupled with his previous medical experience must have

been a better appreciation of how aerial transportation would affect the medical

condition of patients with various types of wounds or illness.

His flying time also put him in touch with some of the young pilots assigned

to Randolph who would later rise to senior positions within the AAF and with

whom he would later be associated during World War II.41 His work in the obstetrics service had introduced him to other officer corps members, but his flying time

is what introduced him to the Army’s fliers. Randolph gave him the opportunity

to get to know the then-current group of Air Corps leaders as well as younger officers.42

Grant’s five-year assignment at Randolph was unusually long, and it ended

in March 1936 when he was ordered to ACTS at Maxwell Field, Alabama, as a

student.43 This was a distinct kudo because he was the first flight surgeon ever

assigned to this prestigious Air Corps school. It also most probably reflected a certain degree of high-level guiding of his career from above, based on his excellent

46

A History of Aeromedical Evacuation in the U.S. Air Force
record and pleasant personality. In fact, shortly after reporting to ACTS, Grant

was selected for promotion to lieutenant colonel.44 Although formally a professional school, ACTS may have been seen as less prestigious than seditious by the

Army General Staff and those who still thought like General Harbord, because the

school was in the process of developing a strategic theory of precision daylight

bombardment that codified the various claims made by previous airpower enthusiasts for a new primacy in warfare of air force.45

Whatever Grant may have thought of the theory of strategic bombardment,

his attendance at ACTS again exposed him to some of the most talented and imaginative Air Corps officers of the time—Haywood Hansell, Laurence Kuter, Hal

George, Donald Wilson, Hoyt Vandenberg, Muir Fairchild, and Robert Olds,

names familiar to students of World War II—men who were to be found on the

faculty and among the student body of what he was now a part. Grant was also

among men with whom he would be dealing with as commanders and important

staff officers during the war. The curriculum was actually broader than might be

gathered from most accounts, which assert that ACTS emphasized strategic theory. The nine-month course was divided among the departments of Air Tactics and

Strategy (280 hours), Command, Staff and Logistics (172 hours), and Ground

Tactics (221 hours). Of the 280 hours allocated to Air Tactics and Strategy, only

110 were devoted to air force, with an additional 41 devoted to bombardment aviation. Attack aviation actually had one more hour in the curriculum than bombardment did.46

Grant’s Maxwell experience further enhanced his identification with the Air

Corps and expanded his circle of aviator friends. In keeping with the major thrust

of the curriculum, Grant chose as the subject of his required ACTS thesis the value

of autogyros to military operations, rather than focusing on their exclusive use as

air ambulances. Within this broader context, he identified the medium-sized autogyro as capable of being used advantageously as a medical ambulance, fulfilling

a need for a more mobile ambulance service to support mechanized armies that

extended over large areas served by congested roads. His evaluation of the

prospects for the procurement of autogyros for this purpose was coldly realistic.

He concluded:

It is questionable, if in time of war, air ambulances of any type

would be available, principally due to the question of production of airplanes for this purpose, in the face of the requirements

in production for the combat services.47

Grant’s view seems curious at first glance, given repeated calls during much

of the preceding decade from within the medical department for the Army to seriously consider aeromedical evacuation as either a supplement to or a replacement

for the ground-based Army evacuation system. One can only conjecture why, but

perhaps the most reasonable explanation is that his close association with Army

aviators at Randolph and Maxwell together with the broader perspective on mili47

Emergence of Organized Aeromedical Evacuation
tary affairs provided by the ACTS curriculum gave him a more realistic view of

what priorities the Army’s airmen had and what the United States would need to

fight another war successfully. This may well have been the time, rather his

assignment to Randolph Field, when, as he was to tell General Arnold in 1943 in

a different context, he “had cast his lot with the Air Force.”48

Upon graduation from ACTS in 1937, Grant was assigned to Barksdale Field,

Louisiana, as base surgeon and surgeon to the 3d Wing of the GHQ Air Force,

which was commanded by his friend, Maj. Gen. Frank Andrews. Grant remained

there for the two years that saw conflict in Europe and in retrospect seem to have

been the rehearsal for the global conflict that erupted in 1939. For medical department officers who had vainly sought to interest the surgeon general and the Army

hierarchy in the value of aeromedical evacuation during wartime, these preparatory wars provided for the first time empirical evidence of aeromedical evacuation’s medical and military value.

The evidence had been accumulating in the United States to support a serious

consideration of casualty evacuation by air. Regardless of the negative official

view of the surgeon general and the War Department, a vast body of information

had become increasingly available to the U.S. military medical community,

arrived at through personal exchanges and reports on aeromedical evacuation systems and through developments in Europe. Both Simpson and Darby in their

Military Surgeon articles prefaced their discussions with brief histories of the

French and British use of air ambulances.

In 1931 the War Department had finally sent an official (and funded) U.S.

delegation to the sixth in the series of international congresses on military medicine and pharmacy, which had been meeting biennially in Europe since 1921 and

where developments in sanitary aviation were periodically discussed in some

detail. Maj. Gen. Robert U. Patterson, U.S. Army surgeon general from 1931 to

1935, served, in his retirement, as a U.S. representative at the Eighth Congress in

Brussels in 1935. Dr. Bainbridge, the reserve U.S. Navy medical officer who had

participated at his own expense as an unofficial U.S. representative in the congresses throughout the 1920s and into the 1930s also reported on the conferences.

His reports were available in various service journals or as separate publications,

including his report on the Fifth Congress in 1929 when the extension of neutral

status to air ambulances under the Geneva Convention was extensively discussed.

By 1935 the United States was also sending official delegations to periodic international congresses on sanitary aviation.49

Information on the use of aeromedical evacuation outside the United States

was widespread. At approximately the same time Grant expressed his disbelief

that aircraft would be made available for air ambulance work in any future war, a

flight surgeon stationed at Randolph Field was publishing another passionate plea

for the U.S. Army to adopt aeromedical evacuation for the seriously wounded. His

rationale was not just that moving a patient by air was better for the patient, it was

that U.S. soldiers should be able to receive the same efficient treatment afforded

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A History of Aeromedical Evacuation in the U.S. Air Force
patients of other nations that had obtained and were using air ambulances. The

journal literature of the time indicates that these other nations included Argentina,

France, Sweden, Poland (whose chief of aviation medicine visited Randolph in

1937), Great Britain (whose first dedicated air ambulance was put into service in

1936), and even the former pariah nation, the Soviet Union, which had decided to

develop an aeromedical evacuation system in 1933. By 1935 the Soviet Union

was reported to have a system with more than ten air ambulances supported by

detachments of personnel in forty-one towns. Several hundred specially trained

doctors and nurses attended patients in flight.50

In June 1939 the International Congress of Military Medicine and Pharmacy

was invited to the United States, and delegates to the Tenth Congress met at the

Willard Hotel in Washington, D.C. An exhibit produced by SAM was reportedly

well received by the attendees. Many of the highest-ranking medical officers of

their respective countries attended, among them, General A. Savornin, surgeon

general of the German army; Senator Count Aldo Castelloni di Chisimaio, recently in charge of medical activities in the Italian campaign in Ethiopia; surgeon Vice

Admiral P. T. Nichols, surgeon general of the British navy; Rear Admiral

Fikentscher, surgeon general of the German navy; Air Commodore H. E.

Whittingham, surgeon general of the Royal Air Force; and Maj. Gen. Erich

Hippke, director of the medical service of the German air force and a proponent

of aeromedical evacuation.51

Whether the actual aeromedical evacuations being undertaken by the fascist

powers, Germany and Italy, were discussed is unknown, but there is reason to

believe that at least the Germans were reticent. Many years later, Gen. E. Evrard,

retired medical director of the Belgian air force, recalled somewhat wryly his

memories of what he termed the inanities introduced into the Geneva Convention

in 1929 concerning air ambulances. From his perspective, lawyers had injected

provisions that were utopian, limiting protection under the Geneva Convention to

aircraft reserved exclusively and permanently for aeromedical evacuation and

painted white and marked precisely in accordance with rules regarding the size

and location of the prescribed red crosses. He pointed out that their impracticality was demonstrated during the Spanish Civil War when the Germans and Italians

quietly ignored these restrictions and used their unmarked three-engine transports—their Ju–52s and Savoia-Marchetti S.73s, respectively—to evacuate their

sick and wounded who had been fighting with Gen. Francisco Franco in Spain.52

Information obtained the following year on the use of Luftwaffe transports to

evacuate casualties from the German Condor Legion would apparently serve as

the catalyst to move the U.S. War Department to act finally on developing an

aeromedical evacuation system for the Army. If news of the Luftwaffe’s successful use of transport aircraft as air ambulances in Spain was the catalyst, Lt. Col.

David Grant, U.S. Army Medical Corps, was to be its agent.

After two years at Barksdale Field as flight surgeon and base surgeon, Grant

was summoned to Washington to assist Colonel Beaven, chief of the medical sec49

Emergence of Organized Aeromedical Evacuation
tion in the Office of the Chief of the Air Corps, apparently on Beaven’s initiative.53

By the time Grant arrived, Beaven was in the Army and Navy General Hospital at

Hot Springs, Arkansas, and Grant became the acting chief of the section, an elevation that he viewed as somewhat problematic, confiding to his diary that it “looks

like a busy place” where he could see “a great deal of grief ahead, especially as I

do not see eye to eye with Beaven, but will have to carry out his policies.”54

He soon learned the truth of his prophecy when he had to deal with the case

of the chief of staff of GHQ Air Force, Col. Clint Russell, who had just been discharged from Walter Reed Hospital as “fit for full military duty,” even though his

diagnosis was “generalized Arterio-sclerosis, hypertension, and beginning aortitis,” and Lt. Col. Malcolm C. Grow, the local flight surgeon, had recommended

that Russell be placed on flying status in spite of a blood pressure of 180/98. Grant

reluctantly approved Grow’s recommendation as a matter of policy, and when he

pursued the matter he found that General Arnold, now chief of the Air Corps, had

established a policy that in effect left the decision whether to continue on flying

status up to a pilot, should he become physically disqualified for flying.55

Professionally, Grant felt this policy of returning Air Corps officers to full duty

when they were obviously unfit for flying of any type was wrong, and he raised

the issue with the surgeon general’s General Hospital Disposition Boards.56

In spite of or perhaps because of Grant’s demonstration of professionalism

and decisiveness in the months that followed, he was able to transcend several

major crises involving General Arnold’s sometimes arbitrary policies while earning and maintaining the general’s respect. These crises included Arnold’s vocal

unhappiness with a flight surgeon who grounded his crew in Hawaii without

Arnold’s knowledge and the unsuccessful attempt of the surgeon general, Maj.

Gen. C. R. Reynolds, and his successor, Maj. Gen. James McGee, to recapture for

the surgeon general’s office the disturbingly autonomy-minded flight surgeons in

the Office of the Chief of the Air Corps medical section.57

With the proclamation of a limited national emergency in September 1939 in

response to the German attack on Poland and the beginning of World War II, the

Army Air Corps was reorganized, and the AAF was officially established on June

20, 1941, as a body coequal with the Army Services of Supply (SOS) and the

Army Ground Forces. The surgeon general was placed under the commanding

general of the SOS rather than directly under Army Chief of Staff Gen. George C.

Marshall. Grant now became the first air surgeon in control of the new AAF medical division, with Arnold’s confidence and support.

Having earlier earned that confidence, Grant was able to take advantage of

the information that emerged in 1940 about the Luftwaffe’s successful use of

aeromedical evacuation. The information was obtained from translations of articles in German military journals that discussed in some detail the use of the

Luftwaffe to evacuate casualties from Spain during the Spanish Civil War and

from Poland during the 1939 German campaign. The Spanish experiences

involved flights up to 1,600 miles long and averaging 10 hours over a route across

50

A History of Aeromedical Evacuation in the U.S. Air Force
the Mediterranean to northern Italy before they crossed the Alps at altitudes over

18,000 feet.58 The articles were particularly significant because they discussed in

detail medical issues and problems associated with the transportation of patients

by aircraft, and they carried descriptions of the evacuation process and the effect

of evacuation by air on patients with specific wounds and illnesses.59 This information provided important empirical data that could be used to establish criteria

for deciding whether a candidate for aeromedical evacuation was in fact

evacuable. In technical terms, it provided crucial data with which to validate theoretically derived regulating criteria that would have to be part of any scientifically based aeromedical evacuation system established by the U.S. Army.

Certainly energized by this new wealth of information, and perhaps with the

assistance of Dr. Richard Meiling who had been studying in Germany and who

would become the air evacuation officer in the air surgeon’s office, Grant worked

in concert with the Army surgeon general and the surgeon of GHQ Air Force in

1940 to develop a T/O for an air ambulance unit composed of Air Corps and medical personnel. Air Corps personnel would operate and maintain the air ambulances, and medical personnel would provide the patient care. As initially conceived, such organizations would operate under the control of the theater commander to augment surface evacuation and perhaps be assigned one to a field

army. Finally approved just before the United States entered the war, T/O 8–455

dated November 19, 1941, called for a medical air ambulance squadron to be

paired with an air transport group consisting of four squadrons: one headquarters

squadron, and three airplane ambulance squadrons. Two of the latter squadrons,

designated heavy, were to be equipped with twelve multiengine transports similar

to the commercial DC–3; the third, designated light, would have eighteen singleengine aircraft similar to the newly developed L–1 liaison aircraft. The medical

air ambulance squadron was to consist of a headquarters section, a single-engine

transport ambulance section, and two multiengine transport ambulance sections.

It was to be manned, literally, by 45 medical department officers and 218 enlisted men, with no nurses, who at this time in the nursing profession were exclusively female. With regard to this proposed organization, it was asserted it “would

lighten and speed the task [of transporting casualties] due to its extreme mobility,

and would be able to render service at a time and place where other means of

transportation are relatively at a minimum.”60 It would remain to be seen whether

aircraft would be available for such dedicated service, something Grant had previously doubted; whether a system for use of these units could be developed, and

how such units would figure in actual theater planning; and whether a role would

be found for female nurses within the new organizations.

Conclusion

If one were to analyze the development of aeromedical evacuation and air

ambulance aircraft to support evacuation by air during the 1930s, certain factors

51

Emergence of Organized Aeromedical Evacuation
would emerge, for example, the state of aeronautical engineering, the reaction of

officials to the sometimes exaggerated claims for military aviation, and the effect

of recent wartime experience on the Army’s Medical Department. In spite of this

conflicting milieu, imaginative individuals proposed that the Army consider using

air ambulances to develop evacuation systems because they perceived that better

patient care and speedier access to definitive treatment could be achieved. The

Military Surgeon provided a venue for a such a dialogue, but it was incapable providing results until the end of the war because of financial constraints and a certain institutional traditionalism within the Army Medical Department. The emergence of a growing sense of corporateness among the Air Corps flight surgeons

only strengthened as the decade wore on.

Events in Europe were key to the Army’s eventual formation of air ambulance units capable of conducting the kind of aeromedical evacuation work proposed by various medical officers. In Europe, sanitary aviation had been developed to a relatively high degree, and both Germany and Italy demonstrated the

medical and military value of transporting patients by air during the Spanish Civil

War, although in ways that made the Europeans’ prior fixation on legal protections

for air ambulances under the Geneva Convention appear irrelevant. The German

attack on Poland on September 1, 1939, led President Franklin D. Roosevelt to

proclaim a state of limited national emergency and begin a program of rearmament which at least eased fund restrictions that had constrained the War

Department’s interest in developing an aeromedical evacuation capability.

Through the forceful personality of David Grant and with the strong support of

Gen. Henry Arnold and aided by organizational changes within the War

Department that placed Grant in a better position to press the idea, a T/O for an

air ambulance unit, one that did not yet include flight nurses, had been approved

on the eve of war. It would remain to be seen how this organization would evolve

and how the nature of a global war with far differing geographic and climactic factors than the U.S. Army had encountered in France in 1917 and 1918 would condition when and how aeromedical evacuation would be used. 

52

A History of Aeromedical Evacuation in the U.S. Air Force
Chapter 3

AEROMEDICAL EVACUATION

AND THE LOGISTIC AND TACTICAL

REQUIREMENTS OF GLOBAL WAR

Although a shortage of funds for the Army during the late 1920s and 1930s

had constrained procurement of air ambulance aircraft and stultified any largescale experimentation with an aeromedical evacuation system, this problem eased

with President Roosevelt’s declaration of a limited national emergency on

September 8, 1939. War Department budgets increased sharply, and historians of

the AAF in World War II described the Air Corps’ share of the funds as “such staggering sums as to be almost embarrassing to an air arm long nurtured on economy.”1 From direct cash appropriations in FY 1939 of $71 million, the Air Corps

appropriation more than doubled to $186.5 million in FY 1940 and reached $2.2

billion in FY 1941.2 The principle that Chief of the Air Corps General Fechet

enunciated in 1931 barring procurement of special air ambulances still held, and

transport aircraft were to be converted for aeromedical evacuation. No specially

designed aircraft, such as the Cox-Klemin, would be procured until many years

after World War II. The issue of the use of smaller air ambulances in wartime was

left formally unresolved although liaison-type aircraft were used for aeromedical

evacuation in both the Pacific and Europe.

Aeronautical engineering and aircraft design, mocking the pessimism of the

pseudonymous “Neon,” advanced exponentially after 1927. During the 1930s

Douglas Aircraft produced a family of comfortable and efficient multiengine

transports that found commercial application in U.S. airlines. The first of these,

the DC–2, proved so revolutionary that it played a role in commercial aviation

similar to that played by the battleship HMS Dreadnought in the British Royal

Navy prior to World War I. Once the DC–2 entered service with a single airline,

its competitors were compelled to discard their existing transports, even if they

53

Aeromedical Evacuation and the Requirements of Global War
were relatively new. Indicative of its capabilities, a DC–2 on its maiden attempt

at transcontinental flight broke all records by crossing the United States in 13

hours and 4 minutes. Capable of 200 miles per hour and having cabin space for

fourteen passengers, the DC–2 forced the airlines into what one historian has

characterized as a period of profitless prosperity because of the DC–2’s higher

cost and the number of airplanes that each airline needed. Perhaps more importantly, the wide-scale use of the DC–2 and later of Douglas twin-engine transports

by the U.S. airline industry helped create not only a surplus of modern transports

but also a surplus of pilots familiar with them and with their use in airlift operations. Many of these pilots would later participate in aeromedical evacuation operations in World War II.3

The Air Corps viewed air transportation in the 1930s primarily as a logistic

tool with strong strategic implications. Increasingly, the Air Corps saw aircraft

engines and other materiel moved through its bases by air as vital in exploiting the

intrinsic mobility of its combat forces. Beginning in 1935, the Air Corps began to

add small numbers of Douglas transports to the Air Transport Group (ATG) controlled by its Air Corps Materiel Division. By December 1941 the size of the

transport forces controlled by its successor organization, the Air Service

Command (ASC), had grown to six ATGs under the command of ASC’s 50th

Transport Wing.4 In 1942 the recently created AAF, reflecting the Army’s reaction

to the Germans’ successes with airborne troops, particularly in the conquest of

Crete, gave its ATGs a new combat mission and reassigned them as the nucleus of

a new troop carrier command.5

While focused on using its new financial resources to buy combat aircraft,

particularly heavy bombers, the Air Corps nonetheless expanded its purchase of

54

A History of Aeromedical Evacuation in the U.S. Air Force

C–47s were used to evacuate the wounded.
transports, largely Douglas DC–3 variants, which made the possibility of developing an aeromedical evacuation system realistic. The prospective availability of

transport aircraft and dissemination of information about the Luftwaffe’s evacuation activities in Spain and Poland led Dr. David Grant in 1940 to press the Army

Medical Department to consider organizing a unit to conduct aeromedical evacuation. He achieved success, although it was not a high priority of the Army’s surgeon general, who had other problems.

Not surprisingly, given the unprecedented situation that the Army faced, the

surgeon general’s office, like some other agencies of the War Department, was

having a great deal of difficulty adjusting to the unprecedented demands of a truly

global war. In 1942 these difficulties led to the appointment of a special committee to investigate the surgeon general’s office, which had the underlying but ultimately unrealized purpose of removing its incumbent, Maj. Gen. James Magee.

Magee had lost the confidence not only of the chief of staff, General Marshall, and

the commanding general of the Army’s SOS, Lt. Gen. Brehon B. Somervell, but

also apparently of Secretary of War Stimson.6 The Wadhams Committee, under

retired Army Medical Corps Col. Sanford Wadhams took testimony from General

Grant, now the air surgeon responsible to General Arnold for the AAF Medical

Service, about aeromedical evacuation, but it ignored the topic in its final report

to the Secretary of War and made only a passing reference to evacuation in general. It noted that, although a few hospital trains and air ambulances were in-theater, no hospital ships had as yet been procured. The committee’s principal comment with regard to the AAF in its summary conclusions was to deplore the surgeon general’s lack of control over the AAF Medical Service. It found the “existence of a semi-independent medical department within the Air Forces” that cre55

Aeromedical Evacuation and the Requirements of Global War

Ground transportation took the wounded from the C–47 air ambulance.
ated “unnecessary duplication of effort, unwarranted segregation of functions, and

undesirable confusion and conflicts of administration which should promptly be

corrected.” It recommended that “every practicable effort should be made to bring

medical service in the Air Forces under the supervision, authority and control of

the Surgeon General.” It added that if this was not a practical course of action, a

clear delineation of authority between the Air Surgeon and Surgeon General

should be established.7

The organization for conducting aeromedical evacuation that the War

Department finally approved, the Medical Air Evacuation Transport Squadron

(MAETS), was composed entirely of medical personnel and included, for the first

time in the short history of military aviation medicine, female flight nurses to provide care for patients in transit via aircraft.

The production of twin-engine Douglas transports, particularly C–47s, a military version of the DC–3, increased rapidly throughout the war years, greatly

expanding the transport capability of the AAF.8 The C–47 was the most prevalent

of the DC–3 variants. It first entered the Air Corps inventory in 1940 when 115

were accepted, and orders were placed for 953 more. Ultimately, more than

10,000 were procured between January 1940 and December 1945, as well as 193

C–53s, another version of the commercial DC–3.9 The AAF also purchased large

numbers of the larger capacity but trouble-prone twin-engine Curtiss C–46s and

the longer range, four-engine Douglas DC–4s, which became the C–54, the standard Army transport flying the global air routes operated by the new AAF Air

Transport Command (ATC).10

ATC’s origins lay in the Air Corps Ferrying Command established in May

1941 to fly combat aircraft from factories to delivery points for transfer to Great

56

A History of Aeromedical Evacuation in the U.S. Air Force

C–47 air ambulance.
Britain under the Lend-Lease agreement.11 The Ferrying Command pioneered

transatlantic air routes to Britain and Africa to provide a courier service for military personnel and later for critical military cargo. In June 1942, to rationalize a

growing patchwork of air transport routes and clarify responsibilities, the AAF

Ferrying Command was redesignated the AAF ATC and given sweeping responsibilities which provided, among other things, an implicit basis for aeromedical

evacuation of casualties. ATC’s responsibilities were for

a. The ferrying of all aircraft within the United States and to

destinations outside of the United States as directed by the

Commanding General, Army Air Forces.

b. The transportation by air of personnel, materiel and mail for

all war department agencies, except those served by Troop

Carrier units as hereinafter set forth.

c. The control, operation, and maintenance establishments and

facilities on air routes outside of the United States which are,

or which may be made, the responsibility of the Commanding

General, Army Air Forces.12

The same directive establishing the ATC redesignated former air transport

organizations as troop carrier units and assigned them to the AAF commander

within a theater of operations. This expansion of transport capability ultimately

made it possible to dedicate excess capability to aeromedical evacuation on a temporary and sometimes basically permanent basis in the theaters of operations and

57

Aeromedical Evacuation and the Requirements of Global War

C–54 aeromedical evacuation aircraft.
the continental United States (CONUS), which was termed the zone of the interior (ZI). However, the AAF formally maintained the policy of not dedicating transports for evacuation and instead relied on retrograde airlift, that is, on the space

available on troop carrier command transports returning from forward airfields

after delivering men and supplies to support frontline troops. This same principle

held true also for the ATC’s long-range aircraft that provided intertheater airlift.

Although the civilian medical profession still viewed aviation medicine

largely as something of a stepchild, the Air Corps’ aeromedical laboratory at

Wright Field focused on the man–machine interface. Their investigations of the

problems aviators faced in the new medium in which they would operate—low

temperature, reduced partial pressure of oxygen, reduced atmospheric pressure,

and intensified gravitational forces—inferentially provided a basis for judging

which patients could be moved safely by air.13

When war came, aeromedical evacuation in the various theaters generally

began without prior planning and was largely dictated by logistic and medical

requirements determined by the local tactical situation and the sharply varied climactic, geographic, and resource circumstances in which U.S. forces found themselves. Many ground force medical officers were indifferent or openly hostile to

the concept of evacuation, although command involvement early in the North

African campaign incorporated aeromedical evacuation as an element of planning

for subsequent operations.

By contrast, the fragmented organizational nature of the Pacific theater and

the lack of command emphasis at the highest levels resulted in a less than optimal

application of aeromedical evacuation as a logistic and medical tool for prosecuting the war. As in all theaters in which U.S. forces faced unforeseen challenges,

58

A History of Aeromedical Evacuation in the U.S. Air Force

Interior furnishings of a C–54 air ambulance.
medical officers learned from sometimes difficult experience what was required

to make an aeromedical evacuation system work. As U.S. ground forces entered

combat against Axis forces in different parts of the world during 1942, AAF medical personnel worked with their ground counterparts at the tactical level to develop procedures through trial and error to meet the requirements for successful

aeromedical evacuation.

The development of the global air routes operated by the AAF’s ATC using

the new four-engine C–54 aircraft provided a new means to return the sick and

wounded to the ZI. Such air transport was especially applicable to those who

required definitive treatment unavailable in the theater and for whom a lengthy

and perhaps rough ocean transit was not desirable. ATC aeromedical evacuation

to the ZI complemented surface means like hospital ships, returning troop transports, or commandeered ocean liners, which were the basic means for returning

casualties to the United States. Generally, patients selected for evacuation to the

ZI were those whose recovery would take longer than the theater’s evacuation

policy, that is, the maximum number of days allowed for recuperation and return

to duty after which a patient, if not recovered, would be scheduled for evacuation to the ZI.

The policy was not immutable because its validity depended on casualty

rates, medical facilities available in-theater, and the rate at which evacuations

could occur. The speed and flexibility inherent in transporting patients by air made

aeromedical evacuation an extremely valuable tool for a theater chief surgeon.14

The medical department discovered that aeromedical evacuation was valuable in

easing the problem of redistributing patients to general hospitals for definitive

treatment or discharge when the evacuees arrived at ports of entry by ship as well

as on aircraft. The AAF gave responsibility for the domestic movement of patients

to the ATC Ferrying Division, which throughout 1944 and 1945 moved increasingly large numbers by air among medical facilities in the ZI, complementing the

more conventional hospital railroad car.

The organizational changes in the War Department that occurred in 1941 and

1942 unquestionably helped foster the development and acceptance of aeromedical evacuation in the Army. The creation of the AAF gave the Army’s airmen control over all their air bases and assigned personnel, including medical personnel.

The War Department reorganization of March 2, 1942, creating a General Staff

and the tripartite Army Ground Forces, AAF, and SOS essentially made the AAF

semiautonomous. David Grant, as head of the medical division in the Office of the

Chief of the Air Corps until June 1941 and formally a member of the Army’s

Medical Department, came under AAF command by the first organizational

change. He became chief of the AAF Medical Service on October 30, 1941, and

reported directly to General Arnold, commanding general of the AAF. By the

1942 changes, Grant found himself no longer subordinated to the much more traditionally minded and conservative surgeon general’s office. He was then perfectly placed to press vigorously for incorporating air transport into the tradition59

Aeromedical Evacuation and the Requirements of Global War
al Army chain of evacuation. The War Department assigned responsibility for

aeromedical evacuation to the AAF in July 1942, and it placed the Army surgeon

general and his office under the commanding general of the new SOS, the strongwilled General Somervell. Somervell was brilliant, tough, and abrasive, an innovator who constantly strove to find ways to get the job done. He prized aggressiveness and efficiency in his subordinates.

By the end of the war in Europe in April 1945, the contribution of aeromedical evacuation to saving the lives of U.S. servicemen and to easing the logistic

requirements for the victorious U.S. Army was well recognized by most in the

Army Medical Department, and General Eisenhower, the U.S. Supreme Allied

Commander, publicly hailed the effort. In spite of a lack of uniform command

emphasis in the Pacific, this type of evacuation became a major factor in the successful prosecution of the war against Japan, notably in the earliest campaigns in

the southwest Pacific when aeromedical means provided the only method for moving Allied sick and wounded out of the combat zone. As the end of the war in the

Pacific approached, planning for the invasion of the Japanese home islands included aeromedical evacuation, and at the war’s conclusion this method was firmly

established as the preferred means for moving sick and wounded U.S. servicemen.

The Organizational Context

The most significant organizational factors in the evolution of aeromedical

evacuation were the creation of the AAF on June 20, 1941; the War Department

reorganization of March 9, 1942, effected by War Department Circular 59; and the

approval of T/O 8–455, Medical Air Ambulance Squadron, of November 19,

1941, and T/O 8–447, MAETS, of February 15, 1943. The first, creation of the

AAF and the devolution of command authority over its facilities and personnel to

the commanding general of the AAF, resulted in the removal of the Air Corps

Medical Service from the command authority of the Army surgeon general; the

second created the tripartite War Department consisting of Army Ground Forces,

AAF, and SOS (shortly to be named more descriptively the Army Service Forces,

or ASF) with which the United States prosecuted the war successfully and which

gave the AAF a strong sense of mission and enhanced the role of the AAF Medical

Service in its achievement. The T/Os represented the Army’s first institutional

recognition of aeromedical evacuation as a formal element of the Army’s evacuation planning. They authorized the organizational structure of the AAF’s

aeromedical evacuation squadrons that actually provided medical care for air

evacuees globally during World War II. The initiative that led to both War

Department T/Os originated with the Army’s airmen in early 1940 led by the thenLt. Col. David Grant, chief of the medical division of the Air Corps, and prompted by the war in Europe.15

T/O 8–455 grew from discussions among the Air Corps medical division, the

surgeon of the Air Force Combat Command, and the surgeon general’s office.16

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A History of Aeromedical Evacuation in the U.S. Air Force
Their discussions focused on the issue of formalizing an organization for

aeromedical evacuation in light of the imminent threat of war and given the precedents in the Luftwaffe’s evacuations of German casualties during the Spanish

Civil War and the Polish campaign. The Luftwaffe’s operations during the former

had been observed by Richard Meiling, an American studying medicine at

Erlangen, near Munich. His clinical experience in the Bavarian capital that served

as the German terminus of the Luftwaffe’s air chain of evacuation from Spain

enabled him to learn firsthand how the system was organized and what medical

and operational issues the Luftwaffe faced. Meiling joined the air surgeon’s office

in the autumn of 1942, so he was not a contributor to the discussions that led to

the War Department’s approval of T/O 8–455 in November 1941. He later became

a key figure in the air surgeon’s office as Grant’s air evacuation officer for most

of the war.17

Grant proposed creation of an air ambulance battalion consisting of an Air

Corps Transport Group plus attached medical personnel. He envisioned a group

composed of a headquarters squadron and three flying squadrons that would operate and maintain airplane ambulances. Two of these squadrons would contain

twin-engine ambulances similar to the C–39 or DC–3 commercial transports; the

third would contain eighteen single-engine ambulances similar to the liaison airplane just developed for the Army.18

The first of thirty-five C–39s purchased by the Army entered the inventory in

1939. Like a number of other Douglas transports purchased by the Air Corps as it

expanded its transport fleet, the C–39 was based on the Douglas DC–2 that had

entered commercial service in April 1934 and had revolutionized commercial air

transportation. The Army used its FY 1936 funds to purchase its first modern

Douglas transport, a DC–2, which went into service as a C–32. Unlike the C–32,

the C–39 had no direct commercial counterpart; it was sometimes dubbed a

DC–21⁄2 because it had a DC–2 fuselage with a DC–3 tail assembly. During the

war, the AAF purchased a large number of variants of the DC–2 and its more

capable successor, the DC–3. The most numerous and heavily militarized version

of the DC–3 was the C–47.

David Grant assumed that, when assigned, the ambulance battalion would

operate from a large field somewhere between 15 and 50 miles from the front. He

asserted that the single-engine ambulances in flights of two or three carrying a

flight surgeon would be able to land well forward in the division area, possibly as

far forward as the battalion aid station, provided there was air superiority.

Although he indicated that the aircraft used would be commercial airplanes with

minor changes, and not aircraft specially designed for aeromedical evacuation, it

is clear that he wanted both types of aircraft dedicated to aeromedical evacuation

and, implicitly, painted in accordance with the Geneva Convention. He identified

the desirable flight characteristics of the smaller ambulance, citing the German

Fiesler Storch liaison plane as a possible model. He also noted that the autogyro’s

possibilities had not yet been exhausted. The characteristics he specified—slow

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Aeromedical Evacuation and the Requirements of Global War
landing speed, high angle of climb, short takeoff roll, and maneuverability—

sounded very much like those of the Cox-Klemin.19 Grant saw the air ambulance

battalion as operating under the control of GHQ but attached to subordinate commands as necessary to augment the currently planned surface evacuation. He

asserted, prophetically, “it will be able to both lighten and speed the task [of evacuating casualties], due to its extreme mobility, and will be able to render service

at a time and place where most needed—specifically, where other means of transportation are relatively at a minimum.”20

A T/O for an aeromedical evacuation unit was initially discussed while the

Air Corps medical division was still formally part of the Army Medical

Department. The Army surgeon general concurred with dedicating aircraft as air

ambulances and brought the initiative to the General Staff. In July 1940 the

General Staff disapproved the T/O for an aeromedical evacuation unit. It reasoned

that airplane ambulances were included as organic elements of the medical department rather than belonging to Air Corps units.21 Their decision was influenced at

least in part by Air Corps comments during staff discussions of the proposed T/O.

Because the air evacuation service was seen as a composite task force for which

existing T/Os would suffice, no need was seen to modify them. The General Staff

suggested that the medical department prepare T/Os for the companion medical

organizations and transport elements of the task force: an ambulance battalion to

be paired with an air transport group of three squadrons, and an ambulance company to be paired with a transport squadron.22

The surgeon general revised and resubmitted the rejected T/O to the General

Staff in October 1940, but it languished without action until the late summer of

1941 when the Air Corps medical department and the surgeon general’s office

agreed it needed further revision in light of the quickening pace of events. The

surgeon general submitted the revised T/O, which was finally approved in

November, three weeks before Pearl Harbor was attacked.23

The delay could well have stemmed from a low priority accorded the subject

by the General Staff during the busy summer and autumn of 1941. However, Mae

Mills Link and Hubert A. Coleman, the historians of the AAF Medical Service during World War II, portray Grant as having believed that the surgeon general was at

least partly responsible. Writing of this episode, they state that Grant submitted a

plan to the surgeon general early in 1941 for the evacuation of sick and wounded by

air, only to have the surgeon general pigeonhole it without comment or action until

nine months later. This purportedly led Grant to go out of channels, carrying a carbon copy of his plan to the General Staff, which led General Magee, who still considered himself Grant’s superior, to go personally to General Arnold and demand

that Grant be disciplined for this action. Arnold’s reaction was to state to both officers that Grant was directly responsible to him and not to the surgeon general.24

In keeping with the General Staff’s previous objection and the Air Corps’ recommendation, the T/O that the War Department approved was one for a medical

air ambulance squadron to be paired with an air transport group identical in com62

A History of Aeromedical Evacuation in the U.S. Air Force
position to the one Grant had proposed. The medical squadron was to comprise a

headquarters section, a single-engine ambulance section, two multiengine ambulance sections, 45 medical department officers, no nurses, and 218 enlisted men.

Pursuant to T/O 8–455, the Army activated the 38th Air Ambulance Battalion as

a test unit on May 25, 1942, at Fort Benning, Georgia, under the command of

Headquarters Second Army.25 Reference to the use of regular transports implicitly called attention to the need for these aircraft to be capable of being converted

into ambulances in accordance with the policy laid down by General Fechet nine

years previously. In early September 1940, the War Department directed the chief

of the Air Corps to maintain plans to convert standard transport airplanes and suitable single-engine airplanes for ambulance use.26

General Arnold personally directed General Grant to get a Douglas C–39 and

draw up plans for fittings required to convert it into an air ambulance. Grant had

the Air Corps Engineering Division at Wright Field adapt a C–39 to carry litters

and fly it to Bolling Field in Washington, D.C., for inspection. He later recommended that all Air Corps transports be equipped to carry the standard Army field

litter, and the Douglas Aircraft Company began producing metal bracket-type litter supports for its DC–3-type aircraft. When installed on the aircraft cabin walls,

these brackets could support three tiers of standard Army litters, for a total of eighteen litter patients.27

The litter-bracket assemblies collectively weighed 218 pounds and were

designed to be stored under the rear cabin floorboards when the aircraft was not

being used for evacuating casualties. Not being permanently installed, the assemblies were subject to removal or loss, as troop carrier units in the theaters would

discover during the war. Douglas also provided metal litter supports for its C–54s,

the militarized version of its four-engine DC–4s. When installed, these permitted

carrying a maximum of twenty-four standard litters.28

In spite of this directive and the progress made in its implementation, responsibility for evacuation by airplane still formally belonged to the Army surgeon

general as part of his overall responsibility for hospitalization and evacuation for

the Army as a whole, but this changed when the War Department assigned responsibility for aeromedical evacuation to the AAF, and Arnold directed Grant to

develop a plan. On October 30, 1941, Grant was reassigned from the Office of the

Chief of the Air Corps to the newly created position of air surgeon in

Headquarters AAF. The governing AAF regulation stated, “the Air Surgeon is

responsible for the Medical Service within the Army Air Forces,” specifying his

duties as advisory as a member of the commanding general’s special staff, and

administrative in conducting the medical department as a technical service. Free

from the surgeon general’s control, it seems clear that Grant felt free to push much

harder for aeromedical evacuation and a wide range of initiatives which he

believed would benefit the AAF and its personnel.29

The later T/O 8–447 for a MAETS flowed from this reassignment of responsibility to the AAF and the consideration by Arnold’s Air Staff of the plan that

63

Aeromedical Evacuation and the Requirements of Global War
Grant and his office developed at Arnold’s direction. Prepared by Col. Wood S.

Woolford, surgeon of the I Troop Carrier Wing whom Grant had brought to

Washington, the plan differed from Grant’s original proposal in one respect: it

included the use of nurses to attend patients during flight. Precisely whose idea

this was is unclear.30

Woolford proposed that the 38th Medical Air Ambulance Battalion be moved

to Bowman Field, Kentucky, near Indianapolis, Indiana, headquarters of the I

Troop Carrier Command, and that its personnel be used as the nucleus of an

Airplane Evacuation Group (Medical). Each group would consist of 49 medical

department officers, 20 AAF officers, 78 nurses, and 458 enlisted men, distributed

among a headquarters squadron and four airplane evacuation squadrons, three of

which would be designated heavy, and one light. A group would be assigned to

the troop carrier command of each air force. Heavy squadrons would be staffed

with medical personnel normally associated with standard C–47 transport groups.

Light squadrons would be assigned twenty small aircraft to provide air ambulance

service from the front lines, and their staffing would include personnel to operate

and maintain the aircraft. Heavy squadrons would include nurses whereas light

squadrons would consist only of officers and enlisted men.31

Grant accepted Woolford’s proposal and submitted it to the Air Staff on July

24, 1942, as a Plan for Development and Operation of Air Evacuation Groups.

The chief of the Air Staff approved it for implementation. The AAF activated the

first of these groups, the 349th Air Evacuation Group, on October 7, 1942, at

Bowman Field and assigned it to the I Troop Carrier Command with an authorized

strength of 49 medical department officers, 20 Air Corps officers, 78 flight nurses, and 458 enlisted men. One month later, three heavy squadrons and one light

were activated and assigned to the 349th, which was given the mission of training

personnel for aeromedical evacuation operations. Although General Grant was the

principal planner, he was assisted by Colonel Woolford, whom he formally designated Air Evacuation Officer in November 1942.32 Grant also worked closely

with Col. E. L. Berquist, a flight surgeon whom he had assigned to the I Troop

Carrier Command to replace Woolford and with whom he was in frequent contact

regarding the training of the aeromedical evacuation units.33

Apparently the plan had not been coordinated with the Air Staff Directorate

of Military Requirements or the Directorate of Air Support, which were separately attempting to deal with a different requirement for air ambulances. They

approached the traditional crash-rescue function, and the issue of liaison-type aircraft for casualty evacuation (such as the L–1, which Grant had referred to)

became bound up with the question of small air ambulances for crash rescue. As

the Air Service flying schools had discovered during World War I, now, in 1942

and 1943, the AAF Flying Training Command was realizing that its training bases

needed small, crash rescue–type aircraft capable of carrying one or two litters to

permit the speedy recovery of injured fliers whose crash sites were either difficult

to reach or entirely inaccessible by ground means.

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A History of Aeromedical Evacuation in the U.S. Air Force
The headquarters of the AAF Southeast Training Center raised the issue with

the commanding general of the Flying Training Command as early as May 1942,

prompting the Air Staff to survey the smaller aircraft present in or scheduled for the

AAF that might be modified to meet the air ambulance requirement.34 The development of liaison aircraft added to the requirement. The Army Field Artillery

School at Fort Sill, Oklahoma, was conducting liaison pilot training with some 250

liaison aircraft at twelve satellite bases. Pointing to two incidents in which injured

students had been subjected to extensive delays in reaching hospitals via ground

ambulance, the commandant of the school requested in March 1943 that a light aircraft ambulance be issued for use in aircraft training accidents.35

Headquarters AAF Flying Training Command noted too that it had repeatedly requested the assignment of hospital aircraft to flying schools, but it had had

little success. It was now requesting that 114 L–1s previously used for glider towing be modified as hospital aircraft and assigned to its training bases. Similarly, in

December 1943 the commanding general of the AAF Western Technical Training

Command at Sheppard Field, Texas, requested that a converted L–1A be assigned

as an air ambulance to support the imminent training of enlisted glider pilots. Two

auxiliary fields were to be used, and although the general said he expected few

accidents, he believed that serious crashes would be likely to occur at considerable distances, “in regions not easily accessible by highway.”36

The problem with such requests was that, as Chief of the Air Support

Directorate Col. David Schlatter pointed out months before, the AAF had procured neither the light planes for such a task nor the pilots to fly them. All the L–1

liaison planes that the AAF had procured were being assigned to the Flying

Training Command as tow aircraft in the glider training program, and the other

light aircraft being procured—L–2s, L–3s, and L–4s—would need to be modified

to carry litters, which Schlatter did not feel were practical.37

Director of Military Requirements Maj. Gen. Muir Fairchild also objected on

both policy and practical military grounds. Addressing the issue in a broad context, he pointed out that the reasons the AAF had consistently followed the general policy of not providing special airplanes for ambulance purposes were

twofold: first, any cargo plane could be used if provisions for carrying litters had

been made, and second, evacuating casualties by air would be limited to areas

well behind the front lines, where larger-type transports normally operated. From

a tactical point of view, he pointed out that “to operate well marked ambulance

airplanes near the front lines cannot but serve to indicate to the enemy the general location of our lines.” He noted further that ground forces required even automobile ambulances be well hidden near the front lines to prevent their detection

by the enemy. If air ambulances were indeed to be restricted to operating only in

rear areas, he saw no requirement for lightweight ambulance airplanes.38 He did

acknowledge that if AAF tactical doctrine was going to call for light aircraft capable of carrying one or two litters, the L–1 was probably the most suitable airplane,

although the Piper aircraft that the Navy was using for these purposes might suf65

Aeromedical Evacuation and the Requirements of Global War
fice. He called for clarification in the form of a clear statement of policy on air

ambulances.39

The formal statement of policy was not published until May 25, 1943, but in

many ways it only codified practices already in use, including retrograde airlift to

evacuate casualties from the combat zone to rear-area hospitals. In August 1942,

at the request of the air surgeon’s office, the chief of the Air Staff had directed

ATC to make aircraft available for evacuating casualties from Alaska, Canada,

Newfoundland, Greenland, Labrador, the Caribbean, and other theaters where

practicable, but only in connection with routine transport operations.40

The policy of using transports on return flights from the front for casualty

evacuation had been proposed by Chief of the Air Staff Maj. Gen. George E.

Stratemeyer and accepted by Arnold in a personal exchange in November 1942.

Both men had agreed that modifying L–2, L–3, or L–4 liaison aircraft as air ambulances should be avoided.41 The formal policy statement of May 1943 reaffirmed

the AAF rejection of designing and dedicating an aircraft solely as an air ambulance, but it took a positive stance toward the idea that helicopters, procured for

liaison purposes, could incorporate the capability to carry standard Army litters.

This possibility was one in which both the air surgeon and the surgeon general’s

office had been interested. The statement also addressed how the air ambulance

requirements at flying training bases might be met.42 The policy statement framed,

with one exception, the process of aeromedical evacuation as it generally was to

be conducted until the end of the war. It laid out a chain of evacuation in which

specific roles were allotted to particular types of aviation units, namely, troop carrier transports and transports of the new AAF ATC:

a. Wounded of Ground Force units are evacuated from collecting stations through clearing stations to Evacuation Hospitals

by Army Service Forces Medical units (ground ambulance).

b. Wounded requiring further movement to the rear to General

Hospitals and which cannot be safely moved by surface transportation, are evacuated from airdromes near the Evacuation

Hospitals to General Hospitals within the Theater by transport

aircraft.

c. Any patient requiring air evacuation from a Theater to the

Zone of the Interior is carried out by aircraft of the Air

Transport Command.

d. Air Evacuation Medical units, organized similarly to the

“Army Air Forces Air [Ambulance] Squadron, Heavy” are furnished by Army Service Forces to render necessary medical

assistance during the air movement of wounded.43

It also stated, “all cargo and transport airplanes can be used for ambulance purposes” and it required that all cargo-type aircraft assigned to troop carrier com66

A History of Aeromedical Evacuation in the U.S. Air Force
mands or ATCs have installations for carrying standard Army litters and, when

practicable, standard British litters. If these installations were removable, stowage

was to be adequate to ensure that the items would remain with the aircraft at all

times.44

The allocation of responsibility for rendering medical assistance during air

transit to ASF aeromedical evacuation units is at best puzzling because reference

to the AAF heavy air ambulance squadron—meaning after November 1942, a unit

manned by medical personnel only—acknowledges the existence of an AAF unit

already constituted to perform exactly this function. It was these AAF units that

performed this mission during organized aeromedical evacuation.

The rejection of air ambulance aircraft as a distinct type was ringing: “the

incorporation of the above general requirements eliminates the necessity for an

airplane designated and designed solely as an ambulance airplane [emphasis in

the original].” The policy did explicitly recognize a special requirement at certain

training stations where flying was conducted with such intensity that an ambulance airplane was required to be in readiness at all times. In such situations, the

policy allowed modification and conversion of appropriate small utility-type

transport aircraft, provided such conversions were held to the absolute minimum

and had been approved on a case-by-case basis by Headquarters AAF.45 A byproduct of Air Staff discussions on how to meet requirements for crash rescue vehicles

would prove extremely useful in 1944 in the European theater when the Air

Mobility Command (AMC) decided to provide C–64 liaison aircraft with factoryinstalled litter brackets sufficient for three patients, allowing these aircraft to be

used for casualty evacuation in an emergency.46

General Fairchild’s opposition in the autumn of 1942 to activate what he

called puddle-jumper squadrons for evacuating the wounded was embodied in the

formal adoption of Military Policy 41 the following May. His successful opposition undercut completely the rationale of the light, air ambulance squadrons proposed in Grant’s plan, one of which had actually been assigned to the 349th Air

Evacuation Group in November 1942. The irony was that the month before, when

the 349th was being activated, Maj. Gen. Carl A. Spaatz had asked for an air evacuation group with both light and heavy squadrons in preparation for the forthcoming North African invasion.47 With the underlying premise of T/O 8–455 now

invalid, Grant and his staff revised their concept of an aeromedical evacuation unit.

The result was T/O 8–447 for MAETS that was published in November 1942.

It called for a unit staffed only with medical personnel. Each MAETS was organized into a headquarters section and four flights. The headquarters section comprised the squadron commander, chief nurse, a medical administrative corps officer, and twenty-nine enlisted men; each flight, headed by a flight surgeon, consisted of six flight nurses and six enlisted medical technicians. One flight nurse

and one medical technician constituted a flight team.48 Because the 349th Air

Evacuation Group lacked a body of experience in aeromedical evacuation, the

AAF disbanded it and activated the School of Air Evacuation on June 23, 1943,

67

Aeromedical Evacuation and the Requirements of Global War
at Bowman Field. In the interim, the 349th had been conducting training with

units organized according to the T/O for MAETS. Responding to urgent calls

from both the Pacific and the North African theaters, the group deployed two

squadrons, the 801st and the 802d MAETS to New Caledonia in the southwest

Pacific and Tunisia in North Africa before the end of 1942. A third squadron, the

804th, left Bowman for the southwest Pacific in May 1943, arriving first in

Australia, then going to Port Moresby before traveling to New Guinea.49 Starting

in late autumn 1942, nurses had been trained at Bowman Field for aeromedical

evacuation duty, although Grant had experienced considerable delay in getting his

first levy from the surgeon general to train six nurses. The surgeon general’s office

was also initially opposed to establishing a nursing division in the air surgeon’s

office, but control of nurses who served in the AAF’s aeromedical evacuation

squadrons clearly fell to the commanding general of the AAF by virtue of the

powers of command given him in June 1941. On November 30, 1942, Grant’s

office made an urgent appeal for graduate nurses, particularly airline hostesses, to

serve in the Army Nurse Corps with subsequent assignment to the AAF

Evacuation Service.50 Indicative of the kinds of problems MAETS might have was

that theater authorities in the Pacific initially would not allow nurses, then exclusively females in the Army, to fly into combat areas.51 Events would show that the

value of casualty evacuation by air would need to be proved to some ground force

medical personnel, but formal aeromedical evacuation units were now in the field,

and they would soon be joined by others.

The development of aeromedical evacuation at this point was largely a function of General Grant’s energy and drive and support from General Arnold, and

Grant’s willingness to do whatever was necessary to accomplish his goals even if

it required bending regulations. Grant strongly identified with the AAF and its

mission, and it was this that undoubtedly influenced General Arnold’s wholehearted support of him throughout the war, particularly in the face of repeated

attempts by the surgeon general to regain control of the AAF Medical Service, and

the ASF commander’s attempts to bring it under his control.52

In the case of the surgeon general, a bureaucratic imperative was clearly at

work—no director willingly gives up a part of his organization—but underlying his

commitment was an unwillingness to accept as valid the sense of separateness held

by flight surgeons that they were different from other members of the Army Medical

Department. If the medical requirements of the Army’s airmen were no different

from those of the other troops, as the surgeon general seems clearly to have believed,

then there was no basis for treating AAF patients differently or for a separate medical service. In the case of the commanding general of the new ASF, General

Somervell’s attempts probably had more to do with his strong personality and confidence in his own management philosophy, which stressed a centralized function.53

Somervell seems to have had more in common with Grant than either of the

two surgeons general who served under him in the SOS/ASF. According to the

historian of the ASF, John Millett, Somervell’s best-known characteristics were

68

A History of Aeromedical Evacuation in the U.S. Air Force
his energy and drive. He was not afraid of responsibility nor loath to cut bureaucratic red tape, and he had a strong sense of urgency in dealing with problems. In

the War Department circular establishing the three major Army commands, each

of their commanders had been enjoined to make use of “judicious shortcuts in procedure to expedite operations.” Perhaps the most descriptive characterization of

Somervell is Millett’s comment, “there were probably few officers in the Army in

1942 better prepared to carry out this injunction to the full.”54

Grant differed from Somervell in having a good relationship with his subordinates and not being feared for his temper, as Somervell undoubtedly was. Maj.

Gen. Norman Kirk, who would succeed General Magee, was known for his energy and combativeness. In a letter to Brig. Gen. Paul Hawley, Colonel Hillman, a

member of Kirk’s staff, noted that Kirk was keeping things hopping in the office

and had lots of fine ideas, adding that “you may remember that he [Kirk] does not

try very hard to avoid an occasional scrap, so when things do not please him, he

personally goes to the top and not infrequently puts his ideas over against strong

opposition.”55 Both Grant and Somervell were much more flexible than Kirk in

their approach to reaching their objectives.

The similarities between Grant and Somervell in this regard provide credence

to Grant’s diary entry of early March 1943 that Arnold told him that with Marshall

and Somervell, the three had decided that he, Grant, would succeed Magee as surgeon general. However, Grant demurred. He would have actually lost much of his

ability to control the AAF Medical Service and the Army Medical Department as

a whole because the surgeon general was organizationally subordinate to the SOS.

Grant told Arnold he had no interest in becoming surgeon general and “had cast

his lot with the Air Force and would sink or swim with it.”56 In practical terms,

that meant using his stewardship to ensure that the surgeon general took due

account of the AAF’s need worldwide.

From the air surgeon’s point of view, neither General Magee, the surgeon

general from 1939 to mid-1943, nor anyone in his office displayed any understanding of aviation medicine or the requirements necessary to keep a highly

trained aircrew physically healthy and operationally poised to carry out the AAF

mission. The enhanced status of the AAF after the War Department reorganization

of March 1942 and memories of the whole prewar history of the Air Corps’ struggles with the General Staff helped give Arnold and his commanders a strong sense

of mission which David Grant and his staff shared. History shows that senior air

commanders in the major theaters of operation developed good relations with and

served their respective theater commanders loyally throughout the war. It also

clearly indicates that generals like “Tooey” Spaatz and George Kenney pressed

the use of airpower and demonstrated its value to their superiors effectively. This

outlook extended to the application of aviation to the medical department in support of the Army’s combat operations.57

General Magee and the surgeon general’s office not only seem to have lacked

an understanding of aviation medicine, they also seem not to have had much inter69

Aeromedical Evacuation and the Requirements of Global War
est in the concept of aeromedical evacuation. This was true even though Grant had

successfully stimulated enough interest in the idea to move the surgeon general’s

office to initiate the process of securing a T/O for an aeromedical evacuation unit.

Maj. Gen. Robert Patterson, Magee’s predecessor from 1931 to 1935, had sought

unsuccessfully to secure funding for twenty-one air ambulances that he wanted

assigned to ground force headquarters. By contrast, even with Magee’s office

engaged in staff discussions about a formal War Department authorization of an

aeromedical evacuation unit in 1940 and 1941, it does not appear that the surgeon

general gave any thought to injecting a test of aeromedical evacuation into the

important Louisiana maneuvers, which concluded just on the eve of war.58

The Louisiana maneuvers, conducted without any provisions for casualty

evacuation by air, convinced AAF flight surgeon observers that aeromedical evacuation was not just a technique for shortening the Army’s traditional evacuation

chain; it would be essential for supporting air force combat operations. The long

ground evacuation routes in isolated stretches of the maneuver area and lengthy

delays in proper medical care called to mind the airmen’s experience with downed

cadets during flying training. The Air Force Combat Command surgeon, I. B.

March, who had expressed the same view in the mid-1920s, reaffirmed his belief

that motor ambulances could never fully support the operations of a tactical air

force because they could not cover the kinds of terrain over which planes could

fly. Malcolm Grow, Third Air Force surgeon to whom March expressed his opinion, concurred and indicated that he would do all he could to promote aeromedical evacuation. He noted:

our chief stumbling block in the way of ambulances has been

the lack of interest on the part of the Surgeon General. After all,

the evacuation not only of the ground troops, but also the Air

Corps casualties are the problem of the Surgeon General, and

until he accepts the airplane as a vehicle I doubt if very much

can be done about it.59

In a small way, the Louisiana maneuvers probably further exacerbated the growing chasm between the Army Medical Department and the Air Corps’ flight surgeons. When the AAF was charged with responsibility for aeromedical evacuation, Grant dispatched part of the 349th’s cadre of medical personnel, including

nurses, to participate in the Texas maneuvers of late 1942.60

As Grow had implied, Magee gave the appearance of being uninterested in

anything having to do with the AAF except getting control of its medical service.

Whatever else may have been involved, the activities of the AAF Medical Service

in 1942 were creating some invidious comparisons with the Army Medical

Department that the surgeon general was now administering as a technical service

for the commanding general of the ASF. According to Grant, in September 1942,

at a time when the discussions on the proposed T/O for an air evacuation unit were

in progress, he asked Magee to accompany him on a trip. The surgeon general

70

A History of Aeromedical Evacuation in the U.S. Air Force
acknowledged that “he did not like planes and in fact had never been in one.”

Grant’s comment to his diary was “no wonder the medical apathy towards the Air

Force,” an attitude that seemed confirmed by Magee’s disinterest in the activities

of the AAF Medical Service when Grant tried to brief him on it.61

An implicit comparison that was obviously embarrassing to the surgeon general was the air surgeon’s “pernicious practice” of getting medical supplies to AAF

units in the United Kingdom outside of the surgeon general’s supply system when

it could not supply the air force units there. General Hawley, chief surgeon of the

ETO, had complained of this in early October 1942 in a personal letter to Col.

Francis C. Tyng, the surgeon and General Staff officer responsible for medical supply. The issue was not, as Tyng implied in his response to Hawley, another example of increasingly arrogant and irresponsible behavior by an AAF bent on independence. It was the simple fact that the normal medical supply process for which

the surgeon general was responsible was failing to meet the medical supply

requirements of the ETO. This included the Eighth Air Force that in October 1942

was the only U.S. combat force in action with the enemy in the theater, although

Operation Torch, the allied invasion of North Africa, was about to be launched.62

Grant knew of this pejorative characterization of his unauthorized supply

activity because someone had given him a copy of the letter in which this characterization had appeared. Neither Grant, who told Arnold that he was putting some

medical supplies on almost every aircraft headed for England, nor the Eighth Air

Force surgeon, Malcolm Grow, whose fliers were the beneficiaries of the practice,

were at all apologetic. Even General Hawley, who had complained initially,

acknowledged later that with the “supply situation being what it is,” he couldn’t

really blame Grow for requisitioning items from him while getting them directly

from Grant. Hawley opined that he would have been “sorely tempted to get supplies where and when I could” if, like Grow, he knew there were things he could

not be supplied with through normal channels.63

Ironically, in view of Col. Tracy Voorhees’s later critical role in helping extricate both General Magee and General Kirk from situations ranging from merely

embarrassing to those that were potentially disastrous, Tyng had given Voorhees

what the latter termed a really chilly reception when he first reported to the surgeon general’s office. Voorhees, then still a civilian, had been assigned to Magee’s

office to assist with contractual aspects of the Army’s purchase of medical supplies. He learned quickly that the surgeon general had not wanted outside help,

and he certainly did not want a lawyer who had been president of a hospital and

who would probably think that he knew something about medical matters.

Voorhees’s predecessor, a civilian referred to only as Mr. Huyler, had been

brought into the surgeon general’s office by Brig. Gen. A. J. Browning of the SOS

to help install business practices in the surgeon general’s supply service, but

Huyler had left after several months of this treatment.64

Other items nurtured Grant’s and Arnold’s distrust of the surgeon general’s

understanding of AAF problems and his willingness to help solve them in a way

71

Aeromedical Evacuation and the Requirements of Global War
they thought he should. Some of the more significant issues of contention between

the surgeon general and his office with the AAF and the air surgeon from 1943 to

the end of the war included recruiting doctors and nurses to staff the AAF Medical

Service, something Grant was forced to do independently when the surgeon general could not; overseeing convalescent hospitals; using nurses’ aides; assigning

recovered aircrew to SOS Disposition Boards; and managing AAF control of general hospitals. The official histories cited previously—particularly Link and

Coleman’s volume on wartime medical support of the AAF, together with Grant’s

diaries—provide rich insights into the relationship between the offices of the air

surgeon and the surgeon general and its on the AAF Medical Service.

Among the issues affecting the development of aeromedical evacuation during the war were the continuing efforts of the surgeon general and the surgeon

general’s superior, General Somervell, to regain control of the AAF Medical

Service. These included General Magee’s vociferous complaints in the autumn of

1942 to the Wadhams Committee, which was investigating his stewardship of the

Army Medical Department; General Somervell’s attempt to enlist Robert Lovett,

the assistant Secretary of War for Air, to support his efforts, based on the fact that

the AAF’s medical needs would be met better if handled by his SOS; and the offer

to Grant by General Kirk when he replaced Magee to get him promoted to major

general if he would accept a position in his office as deputy surgeon general, thus

bringing the AAF Medical Service under Kirk’s control.65 Somervell and Kirk

even tried to have Grant, the moving force of the AAF Medical Service and apparently a special object of Kirk’s dislike, transferred to the China–Burma–India

(CBI) theater in 1944 to replace an ineffectual command surgeon whom Colonel

Voorhees recommended for replacement on one of his periodic field trips to try to

fix the still deficient medical supply system.66

There can be little doubt that had the AAF Medical Service reverted to control by the surgeon general, such a change probably would have slowed if not stultified the development of the aeromedical evacuation system. This is not to say

that the logic of various tactical and logistic situations might still dictate the evacuation of casualties by air, as happened in the early days of the campaigns on New

Guinea and Guadalcanal. On New Guinea in November 1942, when Australian

and U.S. forces began their offensive against the Japanese at Buna and Gona,

C–47s had been used to move casualties over the Owen Stanley Mountains to Port

Moresby not only because no roads were suitable for moving casualties to the rear

but also because the great distances and inherent danger precluded evacuation

attempts by sea.67 U.S. Marine transports began evacuating their wounded from

Guadalcanal in August 1942, using Navy medical corpsmen, before the 801st

MAETS began to operate there.68

The negative mindset toward the idea of moving patients by air held in all

theaters by some senior ground-based surgeons would have predominated in the

absence of an autonomous AAF Medical Service. Plans prepared by Col. Richard

Elvins, Twelfth Air Force surgeon, for aeromedical evacuation in the medical sup72

A History of Aeromedical Evacuation in the U.S. Air Force
port for Operation Torch had been coldly received by senior ground force surgeons. They told him that Twelfth Air Force would not be required to evacuate

any patients by air because the method was too uncertain, unreliable, and hazardous for the sick and wounded.69 As late as mid-1944, Grant’s deputy, Brig. Gen.

Charles Glenn, on an inspection visit to the Mediterranean, CBI, and southwest

Pacific theaters, found good support for aeromedical evacuation by a number of

theater surgeons, but not by the CBI theater surgeon. According to the commander of the 181st General Hospital in Melar, India, the theater surgeon was not in

sympathy with aeromedical evacuation, and it was difficult to get orders authorizing air transportation. As a result, patients sent to him for aeromedical evacuation were sometimes held for long periods.70 Grant found in late 1944 that surgeons in Gen. Douglas MacArthur’s command did not believe aeromedical evacuation was in their patients’ best interests. Grant reported to Arnold that a corps

surgeon on Biak Island had refused to allow patients to be evacuated by air, even

though it was available, on the basis that LSTs (landing ships, tank) would be

available within a few days and the patients would be more comfortable. Grant

was told that the patients were forced to remain on litters, waiting, for 21⁄2 days.

He was also informed that on the morning of November 19, 1944, thirty-six

C–47s had departed Tacloban, Leyte, for the rear with available space for between

200 and 250 patients. While acknowledging there might have been circumstances

of which he was unaware, he reported that several flight surgeons at Tacloban had

definitely informed him that unless they personally sought out patients, they

encountered difficulty in getting the patients evacuated by air.71 A medical department with control of the AAF Medical Service and directed by either Magee or

his successor, General Kirk, would almost certainly have relegated patient movement by air to a more marginal role.

Kirk was an extremely competent orthopedic surgeon who had come to his

position from command of one of the Army’s general hospitals. Notwithstanding

Marshall’s view of Grant as a possible successor to Magee, Kirk was not the chief

of staff’s choice. He represented a promotion track that tended to include senior

medical department officers who, perhaps not unreasonably given the state of the

Army in the interwar years, were more noted for their professional competence as

physicians and hospital administrators than for being adept at planning and having skills to develop and administer a medical system in support of deployed U.S.

troops in combat. General Marshall had sought an officer with more energy, imagination, and flexibility, and above all, greater field experience than Magee possessed.72

Marshall’s choice had been Brig. Gen. Albert Kenner who in 1942 already

had combat experience in World War II as General Eisenhower’s chief surgeon of

the Western Task Forces during the North African invasion. Patton had recommended Kenner for promotion to brigadier on the basis of his conduct during the

landings and his success in saving all but two of some 400 desperately burned and

mangled survivors from a torpedoed troop transport. Eisenhower concurred in his

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Aeromedical Evacuation and the Requirements of Global War
recommendation. During World War I, Kenner had received the Distinguished

Service Cross and Silver Star for gallantry in action, and he later received the

Purple Heart. Of some eleven possible candidates, Kenner was the only one with

any extensive combat experience.73

Nominated to the President by Secretary of War Stimson, Kenner had been

initially accepted by Roosevelt, but before his appointment was announced, the

President had a change of heart. The reason Roosevelt offered to Stimson was that

Kenner lacked sufficient professional stature within the civilian medical community.74 Kirk was the subsequent nominee, and although Marshall loyally accepted

the rejection of his choice, he distrusted Kirk from that point and chose to deal

with him only through the SOS/ASF commander or the deputy chief of staff.75

Although aggressive and energetic, Kirk lacked combat experience and seems

also to have lacked the administrative ability to direct the sprawling enterprise for

which he was now responsible. His reputation in the Army rested upon a welldeserved reputation that he had built through his assignments to a succession of

Army hospitals. During World War I he had been stationed at Camp Greenleaf,

Georgia, providing medical services to recruits. His overseas assignments had

been limited to several years at the Sternberg General Hospital in Manila.76 As the

Hawley-Kirk correspondence reveals, Kirk’s attitude toward the AAF can best be

characterized as bureaucratic, marked by a very aggressive defense of his turf.77 It

is perhaps instructive of his general attitude toward aeromedical evacuation that,

when in 1945 he was to argue vehemently and, as it turned out, unnecessarily for

a draft to secure 60,000 nurses, he told Hawley in a private letter that the nurses

in the evacuation squadrons ought to be reassigned to Army general hospitals

because they were not really needed for most aeromedical evacuation flights.78

The medical supply system worldwide was periodically to be of great concern to Grant. Hawley in 1943 could still write to the surgeon general, now Kirk,

that “the inescapable fact is that our [medical] supply system—in the field as well

as in the U.S.—is about the lousiest thing I have seen in all my service.” The state

of supply affected the MAETS assigned to troop carrier units in the theaters

because they were dependent on theater stocks. In Europe, Hawley was able

through heroic efforts to overcome the medical shortages and deal very successfully with the invasion of the continent and the subsequent Allied campaign in the

west. In this, he was aided immeasurably by Voorhees who went to England and

was instrumental in effecting a reorganization of the ETO SOS medical supply

system for Hawley, who had been plagued by a lack of competent medical administrators and deficiencies in the surgeon general’s supply system.79

The episode provides an interesting additional perspective on Kirk. Writing

to Hawley while Voorhees was in England, Kirk said he was very fond of

Voorhees who had done a “grand job here,” and he would do the same thing for

Hawley. However, he cautioned Hawley that Voorhees was extremely pessimistic—“everything is usually wrong and gone to hell”—but was a “fine fellow,” so Hawley should not take that part of Voorhees too seriously. The point was

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that the situation was in fact, quite desperate, as Hawley, who had repeatedly

sought help from Kirk, was well aware. Actually, Hawley reveals a rather delightful sense of humor in his narrative accounts of a similar visit to the CBI theater

where he was also to find severe supply problems later in 1944.80

In Washington, General Marshall’s confidence in Arnold persisted throughout the war. He supported the growth of the AAF bomber force and the bombing

campaigns against both Germany and Japan. The senior AAF leadership was

imbued with a sense of mission to demonstrate the value of airpower as a warwinning tool and to gain the independence for the air force that airmen had been

seeking since the 1920s.81 They saw their highly trained aircrew personnel as a

unique resource to achieve these ends, and both Arnold and Grant were convinced

by actions of the surgeon general and the SOS, which controlled the general hospitals in the theater COMZ, that the surgeon general and the SOS simply did not

understand the degree to which a qualitative difference existed between a welltrained infantryman and a graduate of the Flying Training Command’s pilot or

navigator training programs. This was not a difference in the value of the human

being; it was a difference in terms of the infantryman’s or airman’s replaceability

and the nature of the stress experienced by each. Aircrews were subjected to inherent and continuous stress whenever they were in the air, even when not in combat, and flight surgeons had to pay continuous attention to their mental and physical well-being if their combat effectiveness was to be maintained. The AAF complained frequently that it took a long time to retrieve an aircrew member once he

had entered the theater hospital system controlled by General Somervell’s SOS,

and this delay adversely affected the aircrew member’s skill level and attitude.

Worse from the AAF’s point of view, and revelatory of a fundamental lack of

understanding about flying and the AAF in general, was the apparently not infrequent action of SOS Hospital Disposition Boards in returning to full duty AAF

fliers with asthma, sinusitis, and asthenia when their conditions precluded their

flying, or returning them to limited duty when there was no such thing as limited

aircrew duty in combat.82 Having to carry such a returned but effectively grounded flier to his unit meant that a replacement could not be requisitioned, compelling

the remaining aircrew to fly more frequently, which in AAF bomber units compounded the already high risk.

A measure of the lack of understanding of even as astute and able a member

of the Army Medical Department as General Hawley was his comment in a private letter to General Kirk in 1943 that “the effort of the Air Force to obtain control of hospitals in areas in which their troops are located arises out of purely personal ambitions.”83 Hawley based his assertion on the fact that when Grant’s staff

visited the ETO, his staff members had responded positively to Hawley’s question

of whether they were satisfied with the medical service given to Eighth Air Force.

Hawley contrasted the attitudes of flight surgeons unfavorably with those of

ground force surgeons who had voiced no similar desires. Hawley’s question and

the answers he received dealt only with the quality of the medicine being prac75

Aeromedical Evacuation and the Requirements of Global War
ticed, not the administrative framework within which it was practiced nor whether

the equally or better qualified AAF medical personnel at Eighth Air Force bases

could have provided definitive care more quickly had they been allowed to do so.

As the report of the Kirk-Grant-Strecker visit to the ETO noted, almost one-third

of SOS station and general hospitals in England were between 20 and 58 miles

distant from airfields and AAF troop concentrations, implying a sometimes

lengthy trip by ambulance over British roads. According to War Department

Circular 165 issued at the behest of Surgeon General Kirk, elective surgery could

be performed only at SOS general hospitals, regardless of the qualifications of the

AAF surgeons at the base dispensaries.84

This was unacceptable from the AAF’s point of view because the more highly trained and selectively chosen pilot or navigator was central to achieving the

AAF mission. Both Arnold and Grant were impatient with obstacles when they

perceived them to be the product of what they viewed as traditional thinking. As

Grant testified before the Wadhams Committee in the autumn of 1942, “It is true

that I do a lot of things sometimes that I may not have the authority for, but I’ve

got a war to fight, and I’m trying to do things.”85 Grant thought the surgeon general and the medical department had neither grasped the nature of the task confronting Army medicine nor were they willing to exhibit the flexibility to find new

ways to meet its challenges.

Grant’s attitude is summed up by a diary comment during his visit to the

Pacific in early 1943. He noted that he had heard nothing but complimentary

remarks about the medical service and that their work at the front has been outstanding, but he was bothered by the complex command arrangements that created overlapping medical jurisdictions and unnecessary medical administrative red

tape. Writing in his diary, he observed, “as I proceed further and further on this

trip, I get more and more discouraged. We Americans have been thinking in terms

of World War I, and the higher echelons are trying to solve the many new problems in those terms.”86

Nandi on Fiji had a dispensary that he termed a disgrace, a problem he saw

as the fault not just of the surgeon but also of command. Serious cases were sent

to the evacuation hospital fourteen miles away over very bad roads, and no

accom modations were available for minor cases, which wasted manpower. On

New Caledonia he inspected an army camp at Plaine des Gaiacs which he called

the worst he had seen in 27 years of service. Its so-called hospital had an open and

filthy operating room lighted exclusively by a hanging 40-watt bulb, and the sick

and wounded had to be sent to an evacuation hospital 35 miles distant over horrible roads.87 One of the problems that the flight surgeons raised with Grant at several locations was that of aircrew sent to SOS hospitals. Cases of flight fatigue

were returned to duty quickly, but they could not survive long. On the other hand,

the physically sick and wounded were held for too long, and it was difficult to

return them to duty. Some who entered the SOS chain were lost to the AAF.88 A

more general problem that obviously bothered Grant was lengthy ground trans76

A History of Aeromedical Evacuation in the U.S. Air Force
portation of seriously wounded or sick patients over the terrible roads that were

the norm on the island bases.89

Grant was correct in his comments about the initial foundering with regard to

medical support in the Pacific and attempts to solve problems by applying

approaches drawn from World War I. Time and the development of LOCs to the

ZI would solve some but not all of the problems, in part because manpower and

materiel for the ETO both had higher priority. As his diary makes clear, the organizational complexity of the Pacific area, the distance and absence of ground communications between stations, and the lack of command support tended to impact

the local line and medical officers more than they did in other theaters. After visits to the major theaters to remedy supply and other problems over the course of

the war, Colonel Voorhees was forced to conclude that the quality of the medical

department in the Pacific compared to that in the ETO was considerably poorer.90

Whatever were Grant’s suggestions for solving some of the problems he encountered—and he made a number of them that seem to have been received seriously

by theater authorities—his inspection trip convinced him that aeromedical evacuation was at least an important part of the solution.

Conclusion

The President’s 1939 declaration of a limited national emergency marked the

easing of the funds shortages that had inhibited the Army’s growth and its modernization during the 1930s. For the Army’s airmen, it meant expansion of Air

Corps troops, fliers and support personnel, and the procurement in ever increasing numbers of modern aircraft, including transports, particularly those produced

by the Douglas Aircraft Company, which made it possible to think realistically

about the possibilities of mass aeromedical evacuation. The new air-minded Army

chief of staff, General Marshall, materially assisted the Air Corps toward greater

autonomy by creating the AAF in June 1941 and naming his deputy chief of staff

for air, General Arnold, to head it. The move culminated in the designation of the

AAF as one of the three major Army commands. The other two were the Army

Ground Forces under Gen. Lesley J. McNair, and the SOS, later designated the

ASF, under General Somervell. Paralleling these larger organizational changes

were changes in the status and autonomy of the medical division of the Air Corps

and of its chief, David Grant. From being a member of the Army Medical

Department and a subordinate of the Army surgeon general, by October 1941

Grant, as the newly designated air surgeon, was responsible solely to Arnold,

commander of the AAF, for all medical personnel supporting the AAF on its bases

and installations. The Army surgeon general remained responsible for hospitalization and evacuation for the Army, but the March 1942 War Department reorganization put limits on his authority by placing him and the medical department

as a technical service organizationally under the SOS commander. The subsequent

assignment of aeromedical evacuation to the AAF allowed Grant to push devel77

Aeromedical Evacuation and the Requirements of Global War
opment of aeromedical evacuation units vigorously, in contrast to the rather dilatory approach to their creation that the surgeon general’s office had taken during

the emergency period between September 8, 1939, and 1941 when the United

States entered the war.

Stimulated by revelations of the Luftwaffe’s use of aeromedical evacuation in

Spain and Poland and initiatives from Grant, who headed the then-medical division of the Office of the Chief of the Air Corps, the surgeon general’s office had

secured approval of a T/O for a Medical Air Ambulance Squadron, T/O 8–455,

modeled on a proposal of Grant’s for an air ambulance battalion. The proposed

battalion would have required integrating medical personnel with dedicated twinengine air transports to transfer patients to fixed hospital facilities in the rear

areas, and small air ambulances for evacuating casualties from as far forward as

battalion aid stations, depending on the attainment of air superiority. The Army

activated a test unit, the 38th Medical Air Ambulance Squadron, at Fort Benning,

Georgia, in early 1942.

The process of approving this T/O once again raised the issue of specialized

and dedicated aircraft for aeromedical evacuation within the ranks of the Army’s

fliers. As a result, General Fechet’s policy of 1931 for using converted transport

aircraft was reaffirmed, and the air surgeon’s concept of dedicated crash rescue–type aircraft for evacuating casualties from near the front lines was blocked

by the Air Staff. Neither light aircraft nor pilots for them had been procured by the

AAF, and it was pointed out that the presence of marked air ambulances was tactically unsound because it would allow an enemy to obtain the position of frontline troops. The principle of retrograde airlift to transport patients in unmarked

transport aircraft used for logistic or tactical purposes was adopted and utilized

throughout the war, although the informal dedication of such aircraft for aeromedical evacuation was limited by circumstance, tactical or medical.

The concept of medical personnel integrated with operational personnel in

aircraft-equipped units was abandoned by Grant in favor of aeromedical evacuation units composed completely of medical personnel that, for the first time,

included nurses. Approval of the new T/O for such a unit, T/O 8–447 for MAETS,

and the foundation of the School of Air Evacuation at Bowman Field provided the

organizational framework and preparation for the MAETS which were to be

deployed to provide aeromedical evacuation services for the Army throughout the

war.

The initial context within which aeromedical evacuation developed was one

marked largely by disinterest toward the idea on the part of General Magee, who

served as the Army surgeon general during the transition from an Air Corps medical division to a quasi-autonomous AAF Medical Service. Subsequent to the War

Department reorganization of March 1942, aeromedical evacuation became but

one element in the relationship between Magee and Grant that carried over to

Grant’s successor, Kirk, and that verged on hostility. The period was also punctuated by attempts by the surgeon general and his superior, General Somervell, to

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regain control of the AAF Medical Service. Bureaucratic factors and Kirk’s combative personality were undoubtedly important elements in this uneasy relationship, but it was rooted in a lack of understanding of aviation medicine that had

existed between flight surgeons and the Army Medical Department from the start.

On the AAF side, Grant and Arnold viewed the surgeon general and Somervell’s

SOS/ASF as continually demonstrating an incapability or an unwillingness to

understand the special medical requirements of the AAF. The AAF focus was on

maintaining the effectiveness of aircrews upon whom, in the final analysis, the

success of the AAF mission depended. Based upon his experiences with the surgeon general’s office in Washington and his observations in the field, Grant also

mistrusted the ability of the Army’s medical leadership to perform with the

required efficiency and flexibility. His skepticism was in part dictated by the attitude of some ground force and SOS/ASF surgeons in the theaters.

In the theaters of operation, the context within which aeromedical evacuation

was integrated into the theater surgeons’ evacuation plans depended on tactical

and logistic factors that varied widely and the emphasis that commanders placed

upon its use. Some ground medical officers did not favor the idea of moving

patients by air, viewing it as either impractical or dangerous. This was particularly true throughout the war in the Pacific theaters, in contrast to Europe where the

initial skepticism of ground medical officers was largely overcome during the

North African campaign by command interest and the all-too-obvious problems

posed by geography and the inadequate transportation infrastructure.

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80

A History of Aeromedical Evacuation in the U.S. Air Force
Chapter 4

THE POSTWAR EVOLUTION

OF AEROMEDICAL EVACUATION

The years following World War II were a period of evolution for aeromedical

evacuation. In contrast to its rapid development and the applications adopted in

the wide variety of combat conditions in which U.S. and Allied forces found

themselves between 1941 and 1945—first in the Far East, and later throughout the

South Pacific, the Mediterranean, and in Europe—the requirements for mass

casualty evacuation that had stimulated its adoption disappeared. The requirement

for aerial transportation of patients, both intratheater and intertheater to medical

facilities in Hawaii and the ZI, remained, as did the local emergency airlift of victims of accidents and natural disasters. Consequently, the policies and procedures

developed for World War II were refined and institutionalized to serve the requirements for airlifting relatively small numbers of patients in a sharply reduced

armed force in a period of peace.

Aeromedical evacuation was a minor consideration for the service medical

departments in the immediate aftermath of World War II. They faced much larger

issues that included what the dropping of the atomic bomb on Japan meant regarding the nature of future war and how to organize the armed forces and their supporting medical services for the defense of the United States in light of the recent

wartime experience. The prospect of atomic warfare injected an additional factor:

the responsibility of the medical services toward the nation’s civilian population

in the event of hostile attack on its cities, including casualty evacuation.

The role the AAF B–29 bombers had played in delivering the atomic bombs,

together with the decisive role that air power had played in the war against the

European Axis powers, meant that the Army’s airmen now had a strong claim for

an independent service that they had sought for so long. It was not immediately

clear whether any future independent air force would also have its own separate

medical service, and thus complete the evolution of the near autonomous status

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Postwar Evolution of Aeromedical Evacuation
that General Grant had achieved for the AAF during the war. The increasingly

equivocal role of the Soviet Union in the attempts of the wartime Big Three to

resolve the issues left at war’s end was a growing concern. Underlying all were

memories of the prewar Great Depression that made Americans in the postwar

period fearful that they might once again find themselves in economic difficulties,

and the desire among some surviving New Deal legislators to expand medical

care to the population at large.

By the beginning of the Korean War in June 1950, the organizational and

functional framework for the modern aeromedical evacuation system had been

firmly established. The major exception was the incipient doctrinal issue between

the U.S. Army and, after September 1947, the newly independent U.S. Air Force

(USAF) regarding the responsibility for moving casualties from the front lines

during ground combat. This became an issue with the use of AAF liaison

squadrons and Army air artillery observation aircraft for frontline evacuation during the previous war. It was kept alive by continued development of helicopter

capabilities after war’s end and by small groups of enthusiasts in the ground

forces and the Army Medical Department who were interested in developing the

capabilities of Army light aviation. The AAF had not wanted to commit itself formally to frontline casualty evacuation. In a postwar world of severely constrained

military budgets and while striving to sell the maintenance of the largest possible

strategic bomber force to Congress and the administration, the AAF was equally

reluctant to divert resources to medical evacuation, though doctrinally it was also

loath to countenance a divergence from the principle of centralized control of airpower.

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B–29 bombers, main bombing aircraft used against the Japanese homeland.
Postwar Perceptions of Aeromedical Evacuation

During World War II, the Army and Marines Corps had increasingly resorted

to removing casualties from the front lines by air. Faced with combat utterly

unlike the trench warfare of World War I and fighting in far-flung theaters usually lacking modern road and rail systems, theater surgeons had found aeromedical

evacuation to be a vital supplement to the surface chains of evacuation. In some

theaters, such as the CBI, the evacuation of casualties by air had been the only

available means to retrieve the wounded and sick from behind enemy lines or

from dense jungle areas lacking ground communications.

With the full support of the AAF commanding general, General Arnold, and

aided by the near autonomy it enjoyed after the War Department’s reorganization

of March 1942, the AAF Medical Service under General Grant had served effectively as the principal proponent of aeromedical evacuation. Its contribution to

victory in Europe had been hailed by no less than General Eisenhower, and contemporary documents generated in the CBI and Pacific theaters demonstrate conclusively just how much medical officers and commanders valued it.1

In the immediate postwar years, some medical department members apparently still held reservations, although their wartime experience had largely answered

the basic questions regarding which patients could be transported by air. The chief

of the Department of Air Evacuation at SAM, Lt. Col. Kenneth Pletcher, asserted to

the annual meeting of the Aero Medical Association in 1948 that aerial transportation of casualties was once again under attack from some quarters as being too unreliable and too dangerous.2 To help silence such criticism, SAM conducted an inflight

study of the effects of transporting patients with different clinical conditions.3

A contemporary sample of the views held by senior active duty and retired

medical officers of the three services offered some support for Pletcher’s comment, but they also included rather more nuanced attitudes toward aeromedical

evacuation. These were in the form of responses to a questionnaire from the socalled Hawley Committee, chaired by then-retired Paul Hawley, the former ETO

surgeon, and composed of the Army and Navy surgeons general and the air surgeon. Rear Adm. J. T. Boone of the Navy’s Medical Corps served as its executive

secretary. The committee had been charged by the new Secretary of Defense4 with

recommending improvements in military medicine, and it gathered information

through hearings and other means. The questionnaire, sent to some eighty-two

senior officers, including one nurse, asked for their views of how well the medical services had fulfilled their mission during the most recent war, and it requested suggestions on how improvements might be made. Questions on hospitalization and evacuation in the theaters and the CONUS were included. Respondents

expressed a considerable amount of support (36 percent Army, 27 percent Air

Force, and 19 percent Navy) for aeromedical evacuation.5

The head of the Army Pathology Institute, Brig. Gen. Raymond Dart, wrote

that he had always strongly urged aeromedical evacuation to the fullest extent,

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Postwar Evolution of Aeromedical Evacuation
including the use of small ambulance planes in forward areas and large transport

planes for long hauls between bases. In an echo of David Grant’s proposal of

1941, Dart called for the surgeon general to control air ambulances and hospital

ships. From the Naval War College, Capt. A. W. Eyer suggested more extensive

evacuation from the COMZ to the ZI, noting that this inferred minimal hospitalizations in the COMZ and a rapid evacuation of casualties, preferably by air.

Retired Rear Adm. C. B. Camerer cited the use of aircraft as perhaps the

greatest advance in casualty evacuation that saved lives and vastly increased

morale. He recommended it be expanded and available in all combat areas. Col.

O. F. McIlnay of the Air Training Command at Barksdale, Louisiana, echoed his

Navy counterpart, Captain Eyer, calling for much greater use of aeromedical

evacuation to permit concentration of definitive medical care in the COMZ and

the ZI.6

Some respondents expressed reservations even while writing positively about

aeromedical evacuation. General Kenner, Eisenhower’s surgeon at Supreme

Headquarters Allied Expeditionary Forces, echoed General Hawley’s view of the

uncertain availabilities of aeromedical evacuation, noting that valuable as it had

been in the ETO, the availability of aircraft was dependent on tactical requirements. In the future, Kenner recommended that Army surgeons should control

dedicated aircraft marked in accordance with the Geneva Convention for medical

use only. Several respondents recommended an increased use of helicopters.

What was not said about aeromedical evacuation in some cases was more

interesting. For example, the only nurse queried, Col. Mary G. Phillips, made

absolutely no comment about flight nurses. Perhaps even more odd was the comment of Col. Robert P. Williams, Gen. Joseph Stilwell’s surgeon in the CBI theater where aircraft had proved to be absolutely essential for evacuating casualties

during the 1943–1944 campaigns in Burma. In Williams’s response, he discussed

evacuation but made no reference to casualty evacuation by air. His unwillingness

to say anything seemingly confirmed, at least implicitly, the attitude attributed to

him by the commander of a general hospital at Melar, India, who told the air surgeon’s deputy, Charles Glenn, that Williams was “not in sympathy with Air

Evacuation.”7

Although these responses suggest a considerable amount of support for

aeromedical evacuation by military surgeons of all services, its future development was clearly going to depend to a major degree on the final resolution of the

struggle between the Army surgeon general and the air surgeon. Kirk, one of the

few board-certified8 medical men in the Army, focused on practicing medicine in

general hospitals using the most advanced medical and surgical procedures, particularly in his own medical specialty, orthopedic surgery.9 Grant, on the other

hand, placed a greater priority on aviation medicine as a means of maintaining

maximum effectiveness of the air forces conducting operations and of enhancing

the practice of medicine in the field through the use of aircraft to increase the efficiency and above all speed in the chain of evacuation. As regards the practice of

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good medicine, it is fair to say that of the two, Grant’s appreciation was better than

Kirk’s that aeromedical evacuation could ultimately obviate the need for some

more radical medical procedures, such as amputations, because the speed of air

evacuation conferred an advantage that slower surface methods could not match.

Securing a consensus about the value of aeromedical evacuation, although

obviously important to its further development in the postwar world, was not the

primary concern of General Arnold and the AAF leadership as the war moved

toward its end. Their overriding priority was attaining the long-sought independence of the AAF from the Army, a goal complicated by discussions on unifying

the U.S. armed forces pressed by the retiring and the incoming Army chiefs of

staff, General Marshall10 and General Eisenhower, as well as by President Harry

S. Truman and influential members of Congress. The intense bureaucratic conflict

that marked these discussions was set against more confusing issues about the

nature of future war that was raised after the dropping of the atomic bomb. These

called into question what role the U.S. military services should play in future

national defense.11

The implications were profound for military medicine as a whole, with special relevance to aeromedical evacuation. If U.S. cities were to be subjected to

atomic bombing as Hiroshima and Nagasaki had been, the imposition of martial

law would probably be required and military medical departments would have to

be called upon to fill the void left by the destruction of civilian medical facilities.

In such circumstances, aeromedical evacuation would be the most likely means

available to transport casualties, including radiation victims, to surviving medical

facilities beyond the bombed area. If future combat resembled the ground operations reminiscent of the recently concluded war, large-scale casualty evacuation

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Postwar Evolution of Aeromedical Evacuation

Immediately after the atomic bomb drop on Hiroshima.
would be called for.12 Resource allocation, planning, and training decisions that

might flow from answers to these and related questions could hardly be made until

the Army airmen’s fight for independence and the future of their quasiautonomous medical service had been determined.

For General Grant, that future had begun to seem threatened in 1945 even

before the dropping of the bombs. Surprisingly, what threatened the considerable

freedom of action enjoyed by the air surgeon and the position of the medical service within the AAF were actions from within the AAF itself. In mid-January

1945, General Arnold suffered his fourth heart attack in two years, and to ease the

burden on the notoriously hard-working and impatient Arnold, Army Chief of

Staff General Marshall suggested that one of the two senior air commanders in

Europe, Lt. Gen. Ira Eaker, be returned from the Mediterranean theater, where he

had commanded the Mediterranean Allied Air Forces, to take over the daily running of the AAF as Arnold’s deputy commander.13 Eaker duly arrived in late

March, and when the European war ended a month and a half later, Arnold selected Eisenhower’s top airman, the senior U.S. air commander in the ETO, General

Spaatz, to go to the Pacific to command the B–29 bombing effort against Japan.

In an effort to avoid fragmenting the strategic offensive between rival commanders in the Pacific, Arnold had earlier prevailed upon the Joint Chiefs of Staff

(JCS) to establish the Twentieth Air Force with himself as commander to control

the B–29 units from Washington.14 With Spaatz and Arnold both focused on the

B–29 strategic bombing offensive against Japan, and with Arnold also in ill

health, Eaker became the key figure in reorganizing the AAF in preparation for

the fight for air force independence and for the major role airmen believed they

had earned in the postwar armed forces. Among the efforts undertaken was a

streamlining of the Air Staff to reduce its size and the number of general officer

positions, in keeping with pressure from the War Department.15

More than just anticipation of postwar reductions was involved. As early as

January 1945 General Arnold, while laying out a foundation for the AAF’s transition from war to peace, specified that one of the governing principles for the

future activities of the Air Staff and major commands be decentralization of operating functions to eliminate the system of rigid control that Headquarters AAF had

developed during the wartime expansion.16 In a visit to London in early March,

Arnold briefed Eaker on what he wanted Eaker to do in Washington, but Eaker

held no staff meetings until mid-July after his late-March return from Europe.

Consequently, the nature of the reorganization that he would propose to Arnold

had not been generally known in the AAF staff.17

To Grant’s dismay, Eaker proposed placing the air surgeon’s office under the

personnel directorate and abolishing the commanding general’s Special Staff,

which included the air surgeon. Such a reorganization would place the air surgeon’s office essentially in the same position it had occupied in the Office of the

Chief of the Air Corps in early 1939. Grant was understandably upset with what

he perceived as the threat to downgrade the role of the medical service in the AAF

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87

Postwar Evolution of Aeromedical Evacuation

and eliminate his direct access to the AAF commander. Justifiable as part of the

Air Staff’s reorganization as directed by Arnold, this organizational change merely heightened Grant’s suspicions of Eaker that he had harbored since returning

from his May inspection trip to the CBI theater. Grant believed there was a personal element in the proposed treatment of the AAF Medical Service, and it

reflected the fact that Eaker would go to any lengths to get rid of him, even if the

medical service was destroyed in the process.18

In late May, Grant had been surprised to observe Eaker escorting surgeon

general Kirk and his wife at a ceremony where Grant had accepted a new

aeromedical evacuation aircraft purchased by donations. Considering the hostility that Kirk had shown toward both the AAF Medical Service and Grant personally, Grant’s suspicions were aroused because Eaker had not mentioned Kirk’s

attendance. Concerned about his future should he once again come under the

authority of the surgeon general, Grant raised the issue in a frank conversation

several days later with General Arnold, who told him that Eaker had recommended that Arnold relieve Grant and appoint Malcolm Grow in his stead. The AAF

commander also told Grant that Eaker persisted to the point where Arnold had

referred Eaker to Assistant Secretary of War Robert Lovett, who also refused, citing Grant’s success in building the AAF Medical Service and his standing as a

national figure. Arnold told Grant that, as long as he was AAF commander, he

would protect him and keep him on his staff and would give him adequate warning of his retirement so that Grant could plan his own.19

The air surgeon was even more disturbed when the very next day he learned

that Eaker had consulted surgeon general Kirk about a paper that Grant had sent

forward for General Arnold’s signature, and upon which Eaker had subsequently

decided no action would be taken. The paper had requested authority for the AAF

to discharge its own medical officers, an action that Congress had been pressing

for but which Kirk had been resisting, to Grant’s frustration.20

Arnold’s uncompromising support of his air surgeon had provided the firm base

from which Grant and his staff had pressed the cause of the special medical needs

of aviators and aeromedical evacuation in both the CONUS and the worldwide theaters of operations. It enabled Grant to fend off efforts by the Army surgeon general, General Kirk and his superior, General Somervell, commander of the ASF, to

regain control of the AAF Medical Service as well as direct access to the chief of

staff. The latest effort had occurred as late as January 1945 without success,

although Secretary of War Stimson did issue a directive in the wake of Kirk’s failure that the surgeon general should have the formal right of direct communication

with the secretary at all times. General Kirk was an old friend of Stimson’s from the

days when Stimson was U.S. Governor General in the Philippines, and subsequent

events indicated that Stimson could and would exercise a veto on the Army’s

attempt to change the medical department if Kirk did not favor it.21

Unsuccessful as Kirk’s bid had been, however, Arnold was preoccupied with

the air war against Japan and with his health. He was intermittently hospitalized
with heart disease and certain to be replaced soon by Spaatz, whom Eisenhower

had indicated he wanted to succeed Arnold. In early July, before Eaker announced

the proposed reorganization, Arnold amplified his earlier remarks, telling Grant

that he knew Eaker and Kirk were friendly and that Eaker “did not believe in our

Medical Service and wanted to turn it over to the Surgeon General.” A month

later, Eaker formally refused Grant’s rebuttal of the proposed reorganization, so

Grant took the only option available, from his perspective. When Spaatz confirmed in a September conversation that he wanted Grow to relieve Grant, Grant

advised him that Grow should be ordered to headquarters immediately as his

deputy and heir apparent because he, Grant, planned to retire in October.22 By the

end of the year, Grant and Arnold had both retired, and in January 1946 General

Spaatz became the next (and last) commanding general of the AAF.

Other major actors who passed from the scene by the beginning of 1946

include General Marshall, who was replaced by General Eisenhower as army

chief of staff, and Secretary of War Stimson, who was replaced by the

Undersecretary of War, Robert Patterson. With Grant’s departure, the foremost

proponent of aeromedical evacuation left the scene at a time when the future of

the independent air force and the future of its medical service were about to

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A History of Aeromedical Evacuation in the U.S. Air Force

Maj. Gen. Malcom C.

Grow.
become critical issues. It was left to General Grow, who became air surgeon on

January 1, 1946, to sort out the future of a medical service for the envisioned

USAF and what role aeromedical evacuation would have in its charter.

Grow’s task was difficult and complex, overshadowed by the immediate concerns of General Spaatz and his staff for independence of the air force from the

Army. An independent air force was favored by General Marshall, as it was by his

successor, although the air-minded Eisenhower was equally convinced that the

Army and an air force should be supported medically by a single medical department. To ensure Eisenhower’s support for the airmen’s primary goal of independence, Spaatz had agreed not to press for a separate air force medical service.23

The fate of the AAF Medical Service had thus been joined to the fate of the airmen’s quest for separation from the Army. Complicating this situation was a move

to unify the armed forces which was supported by the War Department, including

Headquarters AAF, and the new President, Harry Truman.

Unification and the Armed Forces Medical Services

Planning for a postwar structure for the U.S. armed forces began surprisingly early in World War II under the auspices of the far-sighted Army chief of staff,

General Marshall. Marshall recalled all too vividly the rapid demobilization at the

conclusion of World War I and Congress’s refusal to support a large standing

army. As World War II progressed and the success of the allied armies became

more certain, the need to prepare for another postwar period acquired additional

urgency. Legislation granting the President the powers that he had exercised in

ordering the March 1942 reorganization of the War Department would expire six

months after war’s end. Without further legislation to provide a statutory basis, the

War Department would revert to its prewar organization. The role of the AAF as

one of the Army’s three major commands would end, as would the institution of

the JCS on which the AAF commanding general sat in a coordinate position with

the Army chief of staff and the Navy’s Chief of Naval Operations.

On the eve of U.S. entrance into World War II, Marshall brought Brig. Gen.

John MacAuley Palmer, then seventy years old, out of retirement to be his personal advisor on organization and liaison with the National Guard, the modern

equivalent of the colonial militia. Marshall and Palmer had both served in France

under General Pershing, the AEF commander, and both believed that the Army in

wartime should be a citizen army drawn from reserves. Palmer advocated universal military training as the basis for the citizen army.24

After the attack on Pearl Harbor, Palmer spent nearly all his time on postwar

organization, and Marshall formed a postwar planning board in June 1942 to deal

with the question of organization. In April 1943, Marshall directed ASF

Commander General Somervell to begin studying demobilization planning, and in

May the Special Planning Division in War Department’s General Staff was created to review postwar organization.25

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Postwar Evolution of Aeromedical Evacuation
Although the JCS and other joint committees had proved adequate to the task

of coordinating the efforts of the Army and Navy to achieve victory, Marshall and

many in the Army believed these structures had been inefficient, cumbersome,

and slow. They believed the war had demonstrated the necessity for unified command, which was best achieved by a single Department of Defense (DoD).

Postwar austerity also would demand that functions be shared to achieve

economies. These objectives could best be obtained through a single DoD, and in

April 1944 Marshall’s top postwar planner, Director of the Special Planning

Division Brig. Gen. William F. Tompkins, so testified to the House Select

Committee on Post-War Military Policy (the so-called Landrum Committee):

We realize that in the post-war era this Nation will be struggling

under the burden of a large public debt and that while the

Nation will require adequate national security it will also

demand that measures for this security be such as to provide for

maximum efficiency and economy in the elimination of overlapping and duplication and competition between agencies.26

Marshall and the civilian leadership of the War Department favored creation

of a unified structure for the U.S. armed forces having a single powerful civilian

secretary and a single military chief of staff who would direct three separate functional military departments for ground, sea, and air. Reflecting on the interwar

period, and certainly cognizant of the prevailing militia tradition in U.S. history,

Marshall and Palmer favored universal military training for all young men to provide a trained reserve of manpower that could be mobilized rapidly in the event

of another national emergency and avoid the problems faced in building the army

for World War II. In the spring of 1943 General Arnold had established a postwar

planning office in the Air Staff to help shape arguments for air force independence. He and his staff strongly supported Marshall’s views. The War Department

thus presented a unified position on the postwar organization of the U.S. armed

forces, a view the Navy found wanting.

Suspicious that an independent air force would seek to acquire naval aviation,

the Navy opposed its formation and sought to retain the wartime JCS structure

that had served to coordinate rather than direct Navy planning and operations.

Unification was ultimately to be realized, more on the Navy’s rather than on the

War Department’s terms, with passage of the National Security Act of 1947.

The Eaker-proposed Air Staff reorganization, to which Grant had so vigorously objected, went into effect September 17, subordinating the Office of the Air

Surgeon to the assistant chief of the Air Staff for Personnel. It became effective,

but not without some apparent reservations on the part of General Arnold.

According to Grant, Arnold voiced misgivings in mid-August about the reorganization, although he believed the process had gone too far for him to intervene.27

To at least help preclude the perception by AAF commanders that the organizational change affecting the medical department should be taken as diminish90

A History of Aeromedical Evacuation in the U.S. Air Force
ing the importance of the AAF medical service, Arnold published a letter in late

August to all AAF commanding generals and commanding officers. In it he stated, “there must be full and intelligent awareness of our responsibility for and the

importance of our medical service and of its position and relationship in the organizational structure of each echelon.” He listed a series of clearly fundamental

principles essential to the function and operation of the medical service stressing

the need for commanders to develop a close relationship with their surgeons and

cautioning against lay administrative control that would prevent the surgeons

from exercising their professional responsibilities to the sick and wounded.28

Arnold announced his decision to retire in early November 1945, and his concerns

about the Air Staff reorganization may have been a factor later that month in his

directing Eaker to give Spaatz the job of determining the permanent status of the

AAF. Probably more important was General Eisenhower’s imminent succession

of General Marshall as Army chief of staff, which occurred on November 20,

because Eisenhower wanted Spaatz to succeed Arnold as AAF commander.29

Spaatz’s role would be important to the new air surgeon, Malcolm Grow, and

to the future of the medical service. In spite of his agreement with Eisenhower not

to press for a separate medical service as part of air force independence, Spaatz,

unlike Eaker, was clearly not content to return full responsibility for medical support of the AAF to the surgeon general. He persuaded the first postwar board

charged with examining the War Department organization, the so-called Simpson

Board,30 to reaffirm the AAF commander’s “command responsibility for all medical installations and units of the AAF and for all medical personnel assigned to

the AAF.”31 Spaatz also helped convince the board to define the surgeon general’s

major task in his role as a technical officer of the War Department and chief medical officer (CMO) of the Army as setting Army policies for hospitalization, evacuation, and care of the sick and wounded, and also specifying that the surgeon

general could issue directives to the medical officers in subordinate major commands of the War Department only through proper command channels, and not

directly.32

Malcolm Grow, now Spaatz’s air surgeon, agreed with David Grant on the

need to preserve the wartime position of the AAF Medical Service in a peacetime

air force. After Grant’s departure, Grow’s office developed a medical master plan

for medical support of an independent air force. This was done in conjunction

with a new phase of postwar planning by the Air Staff begun on October 15,

1945.33 The Grow-supervised master plan incorporated as one of its major

assumptions that an independent air force would provide its own complete medical service including regional hospitals, which in the CONUS were the equivalent of the wartime-developed AAF general hospitals controlled by the Army surgeon general. However, in September 1945 surgeon general Kirk had established

a postwar planning board on the assumption that the AAF would continue as a

component of the War Department and that the functions of hospitalization and

evacuation for which the ASF had been responsible would devolve upon the sur91

Postwar Evolution of Aeromedical Evacuation
geon general, whatever the fate of the ASF. The surgeon general would serve the

War Department as a whole.34

Grow’s approach was undercut by the Eaker-inspired Headquarters AAF

reorganization of September 1945, and even more importantly by Spaatz’s agreement with Eisenhower not to press for a separate air force medical service. The

AAF Medical Service for which Grow found himself responsible in June 1946,

following implementation of the Simpson Board’s recommendations, was restricted largely to base dispensaries. The wartime regional hospitals in the United

States (essentially AAF-controlled general hospitals) and the station hospitals

serving major AAF bases were phased out gradually, and even SAM was reassigned to the Air University in April 1946. The surgeon general had control of all

general hospitals and Army-wide responsibility for the technical administration of

medical services, and Kirk, as the senior medical advisor once again to the Army

chief of staff, was superior to the air surgeon in the Army medical hierarchy.35

Kirk’s situation, and perspective, was clearly reflected by Brig. Gen. Guy Denit,

Kirk’s immediate successor, when he stated in December 1946, “the surgeon general does not recognize the existence of an AAF medical department officer, nor

of an Army Ground Forces Medical Department Officer.... The mission of the

Medical Department is to serve the interests of the Army as a whole and not a particular command or branch.”36

At least the aeromedical evacuation function within the War Department

remained officially with the AAF. With Headquarters AAF adapted to peacetime,

at least on an interim basis, by Eaker’s September reorganization, the new AAF

commander had directed changes to the AAF organizational structure in March

1946 to prepare for the changed circumstances and mission requirements of the

postwar world. The reorganization provided the core for the command structure

that would characterize the air force when it achieved its independence in 1947.37

An expanded ATC was directed to provide air transport for all War

Department agencies except those served by troop carrier commands and some

local services overseas, and for any government agency as required or directed.

ATC was made responsible for air evacuating the sick and wounded from overseas theaters and between points within the United States. The transport command

included a new Air-Sea Rescue Service, a designation implying possible crash

rescue and frontline evacuation operations like those performed by AAF liaison

squadrons in the war just past.38

In the immediate wake of the Japanese surrender, ATC’s aeromedical evacuation flights had been chiefly filled with U.S. POWs freed from Japanese captivity. Subsequently, the command developed a schedule of aeromedical evacuation

flights to the United States and Hawaii to move members of the occupation forces

in the Far East and Europe needing definitive or specialized treatment that the

Army general hospitals—in-theater and frequently sited in former enemy medical

facilities—could not provide. Intratheater movement of patients continued to

require theater airlift, generally by reconfigured transports of the theater troop car92

A History of Aeromedical Evacuation in the U.S. Air Force
rier commands. Of more than 4 million passengers carried by ATC during the

almost four years of war, its medical evacuation aircraft carried 339,000 patients:

103,000 from battle zones to base hospitals; 121,000 from base hospitals to the

United States; and 115,000 from U.S. ports of debarkation to domestic hospitals.

By comparison, from the end of the war until May 1948, ATC evacuated between

12,000 and 15,000 patients per year.39 In the absence of combat casualties, the relatively small number of patients requiring this service between the end of World

War II and the beginning of the Korean War would, in the interests of economy,

lead to decommissioning the remaining hospital ships that had served in World

War II.40

In all these cases, the absence of mass casualties from combat and sickness

meant that fewer medical personnel were needed. Most of the Medical Air

Evacuation Squadrons (MAESs) assigned to theater troop carrier units were

decommissioned and their personnel assigned to the ATC’s 830th MAES, which

served as an umbrella organization for ATC from which flight nurses and medical

technicians were assigned to aeromedical evacuation missions. Unfortunately,

even the reduced requirement for such personnel was not easily met because so

many doctors, nurses, and medical technicians had left the armed forces.41 In mid1946 to help fill the need, General Grow reopened the School of Air Evacuation,

now at Randolph Field, Texas. Its operations had been frozen at the declaration of

peace, but the shortage of medical personnel in the armed forces as a whole in the

postwar years presented a bothersome problem that required constant corrective

efforts. This shortage was also a major factor affecting the various proposals that

impacted the future of the medical services during the struggles over unification.42

While the aeromedical evacuation system was adjusting with some difficulty

to an essentially peacetime mode during 1946 and 1947, negotiations reached closure on the basic structure for unification of the armed forces. Based on the success of negotiations between Maj. Gen. Lauris Norstad, the War Department

Director of Plans and Operations (and former AAF Director of Plans), and Vice

Adm. Forrest Sherman, the Navy’s deputy Chief of Naval Operations, the

President announced on January 16, 1947, that Secretary of the Navy James

Forrestal and Secretary of War Robert Patterson had agreed to support legislation

for a Secretary of National Defense.43

The Secretary of National Defense would be responsible for coordinating

three military departments—Army, Navy, and Air Force—each with a military

head and under a civilian secretary. The three military heads would comprise a

JCS, and the three departments would be administered as a single unit by the

Secretary of Defense. Although the provisions did not call for a JCS chairman,

they included a Chief of Staff to the President. In addition to the already established Central Intelligence Agency, the negotiators agreed to support legislation

for a National Security Resources Board. The individual and collective functions

of the armed forces—the so-called roles and missions of each component—were

to be identified in a presidential executive order which had been drafted and pro93

Postwar Evolution of Aeromedical Evacuation
vided to the participants, to be issued when the President approved the final legislation.44 With the exception of the resources board, which presumably would

(and did) address the mobilization and utilization of medical personnel and

resources, the agreement was silent about the future organization and functions of

the military medical services. Even before the legislation was introduced, these

issues arose with a vengeance.

Anticipating the passage of unification legislation, Chief of Staff General

Eisenhower appointed a special War Department board on January 20 headed by

Brig. Gen. William Hall, the War Department deputy chief of staff for Personnel

and Training, to identify and recommend solutions to major unification problems

that the Norstad-Sherman agreement posed for the Army, pending unification legislative proposals.45 Among the major issues was whether the Army and the new

USAF would be supported by common service organizations, including medical

services. The question for Air Surgeon Grow was whether the planned organic

medical corps of an independent air force developed by his staff would be put into

effect, or whether the Army surgeon general and the Army Medical Department

would continue to provide the bulk of medical support, including hospitalization,

as it had to the AAF under War Department Circular 138.46

At least for Eisenhower’s tenure as chief of staff, the answer was a given. In

his view, common technical support agencies would preclude the duplication evident during the war and would facilitate economies. Eisenhower was an enthusiastic supporter of air force independence, yet he felt so strongly about eliminating

duplication that when he heard some AAF leaders express reservations about

whether support by War Department agencies would be effective, he reminded

Spaatz of their agreement about no separate services for an independent air force.

Whatever was in Eisenhower’s mind, his comments to Spaatz must have at least

implicitly raised the possibility of losing the chief of staff’s support for air force

independence. Eisenhower told Spaatz pointedly that he would “oppose the whole

plan with all the emphasis I can possibly develop” if the idea of separate services

was developed in Congress or elsewhere.47

Eisenhower was particularly concerned about the idea of the independent air

force having its own medical service, and he favored a consolidated medical organization. Worse from the air surgeon’s point of view and contrary to thirty years

of struggle by the Army’s flight surgeons, Eisenhower also appeared to accept the

surgeon general’s tacit rejection of the validity of aviation medicine as a specialty that justified a separate medical service. In criticizing the air force medical

plan, Eisenhower wrote Spaatz that it would be unwise to overemphasize the specialty of aviation medicine “to the point where the services would be duplicating

overheads in every direction.” The Hall Board, perhaps mindful of the chief of

staff’s views, stressed that an independent air force would not set up separate supporting services, like an Air Force Medical Corps.48

The issue—discussed by the surgeon general and the air surgeon before the

Hall Board, which essentially espoused the Circular 138 arrangements—was

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A History of Aeromedical Evacuation in the U.S. Air Force
raised again early during testimony on the draft legislation on unification in

March before a quite different audience: congressional committees considering

the legislation. During these hearings, Congress was very concerned as a result of

wartime shortages to organize the military medical services in ways that would

make the most efficient use of doctors for civilian and military situations, particularly in light of the possibility of nuclear war. In a comment almost certain to

raise the hackles of virtually all of the American Medical Association’s members

as a possible step toward socialized medicine, Chairman Chan Gurney of the

Senate Committee on the Armed Services opined that there might be a need to

militarize the civilian medical community in some areas to meet the catastrophe

of a nuclear attack.49 Similar concerns about the ultimate implications for civilian

medicine of consolidating the federal medical services as a whole, and not just

those of the Army and Air Force, were to underlay the deliberations of the socalled Hoover Commission. President Truman created this commission (formally,

the Commission on Organization of the Executive Branch of the Government) to

study ways of reorganizing the executive branch of government to make it more

efficient. The wartime shortage of doctors concerned Congress, but residual interest remained on improving the medical care of the population at large, which

some saw as an unrealized aspect of President Roosevelt’s New Deal legislation.50

Two aspects of these deliberations are relevant: discussions on whether the

armed forces medical services should be consolidated, and what prominence did

the medical services give aeromedical evacuation. The consolidation model,

favored by General Kirk, focused on hospitalization and tended to leave field

medicine and evacuation as secondary activities. The prominence given aeromedical evacuation in discussions and committee reports reveals the attitude toward

this technique compared to its actual use and development during the war.

The month before Kirk appeared before the committee, General Eisenhower

repeatedly offered his conviction that the medical services could provide an excellent starting point for unifying the armed forces as a whole.51 He believed strongly in a single medical service with three independent components for the unified

armed force, and he believed the probable nature of future wars demanded that

there be a strong defense secretary with directive authority, rather than merely a

coordinator, and an equally strong director of unified medical services. Again

using unified medical services as his model, he commented,

For example, in looking at the picture of what war might be in

the future, take a medical service. A medical service is no

longer going to be concerned merely about evacuation of people out of St. Lo or out of Iwo Jima. I have no doubt that eventually the medical service of the whole United States in global

war will be under one man. And that means the medical people

are taking care of the wounded in Chicago and Portsmouth, just

the same as at the front.52

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Postwar Evolution of Aeromedical Evacuation
General Kirk’s testimony dealt directly with the medical services, and he initially merely stated the War Department position that, because nothing in the proposed legislation specifically dealt with the medical department, the existing situation would continue for two years while the Secretary of Defense decided what

the final medical organization should be. When asked his personal opinion on the

most effective future organization, Kirk described a highly centralized, single

integrated medical service that would effectively be a fourth military department.

It would be commanded by a powerful director general who would be a member

of the Secretary of Defense’s staff and would provide the secretary with advice on

the health and medical care of all components of the armed forces. The director

general’s control would be broad. He would “prepare policies, plans, and directives governing the medical service; operate, command, and administer all medical department troops and installations not attached to the major forces.”53

The director general and the Armed Forces Medical Service (AFMS) he commanded would be responsible for common hospital services including all fixed

hospital installations: general, station, and convalescent in the CONUS, in overseas departments, and in the COMZ during war. The proposed AFMS would also

operate a preventive medicine service, a common research and development

(R&D) program, clinical research laboratories, the Army Medical Library, and the

Army Institute of Pathology, and the AFMS would conduct common procurement, storage, and distribution of medical supplies. The director general would

have complete responsibility for procuring, technically training, and assigning

military and civilian employees. He would be responsible for preparing and

defending budgetary estimates for the AFMS as well as for constructing and

repairing all required medical installations. Last on Kirk’s list of charges placed

on his unified medical service was responsibility for coordinating and directing

evacuation of the sick and wounded by air and sea.54

Deputy directors would direct operations of the new medical service in the

CONUS and overseas at installations other than those attached to a major force.

Each major force, that is, Army, Navy, or Air Force, would have a surgeon general appointed from the medical service and additional attached medical troops as

determined necessary by the Secretary of Defense (on the basis of the director

general’s recommendations). The surgeon general of each force would be responsible for the specialized, technical, and tactical training of all attached medical

personnel and for R&D pertaining to his special needs. All examples of these special needs pertained to field medicine:

Surgeon General of the Army: Tactical training of battalions

and regimental detachments, medical battalions, medical

groups, dispensaries, field and evacuation hospitals.

Surgeon General of the Navy: Specialized and tactical training

of attached medical personnel for duty aboard ship, including

hospital ships; naval air arm, and [related] research and devel96

A History of Aeromedical Evacuation in the U.S. Air Force
opment...; dispensary service evacuation of sick and wounded

by ship.

Surgeon General of the Air Force: Specialized and tactical

training of attached medical personnel, such as flight surgeons

and nurses, research and development as it applies to the health

of flying personnel, air evacuation of the sick and wounded,

and dispensary service.55

The rationale Kirk offered to support his proposals included identifying the primary missions of Army and Navy and the acute and serious scarcity of trained

medical personnel during wartime and the wasteful parallel systems of hospitalization, evacuation, procurement, storage, and distribution of medical supplies.

Kirk also asserted that “the medical service during the war, no matter how good,

could have been better had there been a single integrated medical service”—a

proposition that General Grant and his flight surgeons would no doubt have contested vigorously.56

It seems clear from the structure of the proposed organization that the AFMS

core activities would focus on hospitals and clinical medicine and that field medicine—emergency surgery and interim medical procedures in support of patients as

they moved along the chain of evacuation toward definitive care—would have less

importance within the new organization. Medical personnel would be attached to

a force and presumably rotate periodically back into primary hospital or hospitalrelated activities. This was not surprising given Kirk’s background and the focus

on Army hospitals among prominent members of the Army Medical Corps.

Testifying before the Senate Appropriations Committee on military appropriations

for FY 1946, Kirk apparently did not think it worth mentioning that aeromedical

evacuation had played a major role in the more rapid evacuation of the wounded

that he cited as one of the factors producing decreased mortality from certain kinds

of wounds as compared with similar statistics from World War I. In fact, War

Department Field Manual FM 8–35, published a few months before Kirk’s testimony, specified, “evacuation of the sick and wounded by means of water transportation is mandatory if a military force is operating in a theater separated from

the zone of the interior by a large body of water.” The manual also specified, somewhat contradictorily, that “evacuation by air will be utilized whenever feasible.”57

An anecdote related by a later Air Force surgeon general is suggestive of

Kirk’s relative priorities compared to Grant’s, with whom he was in contention for

control of the AAF Medical Service during the war. General Pletcher relates that

he was present at a conversation between the surgeon general and air surgeon

when Kirk told Grant “Look Dave, don’t separate yourself from us [the U.S.

Army Medical Department]. All you will do is get beat over the head by the line

of the Air Force.”58

Kirk’s concept with its stress on clinical medicine was in keeping with the

emphasis he had begun to place on additional graduate training and specialization,

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Postwar Evolution of Aeromedical Evacuation
including board certification for members of the medical department. While professionalizing the department was obviously a natural goal, given Kirk’s background, it also had an expedient aspect: it was a way of meeting the expectations

of the new breed of doctors and making the Army a more attractive option while

simultaneously upgrading the department’s professional skill levels. Kirk’s successor Maj. Gen. Raymond Bliss continued this program, but at the end of 1949

a shortage of 1,200 medical officers remained.59 Because of Kirk’s inherent disinterest in field medicine, when coupled with the personnel and organizational

uncertainties of the late 1940s, the constituency for aeromedical evacuation was

not necessarily strong within the Army, except probably at SAM and in the offices

of air surgeon and the command surgeon of the ATC.60

The final product of the hearings on unification legislation was the National

Security Act of 1947 which became effective September 18, 1947.61 The act,

signed by President Truman on July 26, 1947, created a national military establishment comprising three military departments—Army, Navy, and Air Force—

under a Secretary of Defense who had coordinating rather than directive authority, as the Navy had favored. The act left open for two years the final form of the

medical department for the newly independent Air Force while the new Secretary

of Defense decided what services being performed by the Army, including medical services, should be transferred to the Air Force.62

Kirk’s ideal proposal was not adopted, but the surgeon general was left in

charge of providing medical support for the new Air Force in consonance with the

oral agreements between Generals Spaatz and Eisenhower that were codified and

published on September 15, 1947.63 The fundamental policy agreement stated that

service support of the Air Force would continue “substantially as now constituted” and, specifically, “chaplains and medical personnel will remain with the

Army.” General hospitals for the Army and Air Force would be operated by the

Army, although the Air Force could operate station hospitals and provide hospital

service to members of either service depending on prior agreement. The surgeon

general’s traditional status and powers were reaffirmed as “Chief of the Medical

Department of the Army and senior medical staff officer of the War

Department.”64

The period following creation of the national military establishment was

marked by the deliberations of a wide number of boards and committees.

Considered were various proposals for organizing the military medical services as

a separate entity or placing it within the larger context of the federal medical services, which included the Veterans Bureau and the Public Health Service. The situation was so confusing to observers that a trade publication, Washington Report

on the Medical Sciences, published a four-page directory in mid-September 1948

of “Washington committees, boards, etc., having responsibilities in the medical

field which have sprung up in recent months.”65 Having the greatest influence on

the future organization of military medicine were the Committee on Medical and

Hospital Services of the Armed Forces, appointed by Secretary of Defense

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Forrestal and generally known as the Hawley Board after its chairman, Paul

Hawley, Eisenhower’s former ETO surgeon, and the two task forces of the

President’s Commission on Organization of the Executive Branch of the

Government (the Hoover Commission)—Ferdinand Eberstadt’s Committee on

National Defense, and the Medical Services chaired by General Kirk’s wartime

medical supply troubleshooter, Tracy Voorhees.66

The principal committees considered proposals like Kirk’s for a single medical service coequal with the military departments, separate organic medical

departments for all three services, and organic medical departments with a common general hospital system. Although aeromedical evacuation may have figured

in the deliberations of these various boards and committees, it is significant that

virtually no mention of the issue appeared in any of the final reports.67

The continuation of the situation whereby the Army Medical Department

provided medical services to the Air Force as part of the agreements attendant to

unification was profoundly disappointing to the air surgeon and his staff, but it

was not to hold. After much discussion, the Secretary of Defense accepted the

position of the Eberstadt Committee that each service needed to control its own

medical service to conduct its mission most effectively. On July 1, 1949, the

USAF Medical Service came into being with Malcolm Grow as its first surgeon

general. The first essential function that the new medical service identified was

“to operate air medical evacuation systems for both the Army and the Air Force.”68

Richard Meiling, David Grant’s former air evacuation officer and executive officer, played an important role in achieving the transfer of functions from the Army

to an independent Air Force Medical Service and in decisions that furthered the

development and acceptance of aeromedical evacuation.69

Conclusion

Although the aeromedical evacuation system may have been peripheral to the

concerns of the many committees, boards, and individual leaders dealing with

issues of unification and control of the service medical departments, the system

continued to evolve in the postwar period under the effects of external events and

decisions arising from the drive to consolidate functions and enable the services

to live within severely constrained postwar budgets. The AAF reorganization

directed by Spaatz in March 1946 had charged ATC with aeromedical evacuation

as part of its responsibility. ATC was to provide air transport services to the War

Department and other agencies, but its limited aircraft resources precluded its giving a high priority to aircraft dedicated exclusively to air transport, even if its

commander had wished to do so. Immediately after war’s end, the AAF as a matter of policy began releasing transport aircraft to civilian airlines in an effort to

strengthen the airline industry. The industry’s economic health was essential to the

nation’s aircraft manufacturers and to the AAF, which ultimately depended on the

manufacturers’ production capabilities.70

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Unification of the armed forces, begun in 1947 with the creation of the DoD,

and events in Europe placed additional requirements for air transport upon the Air

Force that necessarily affected aeromedical evacuation. As a natural step in consolidating functions as unification took hold, on June 1, 1948, the Military Air

Transport Service (MATS) was created by integrating the Naval Air Transport

Service with the Air Force’s ATC.71 The beginning of the Berlin airlift on June 24,

1948, in response to Soviet closure of the land routes into the former German capital created a demand for the four-engine C–54s. These were the standard aircraft

for intertheater air transport of passengers, high-priority cargo, and patients, and

the withdrawal of a significant number of them strained the capability of MATS

to maintain the schedule of aeromedical evacuation flights that it and its predecessor organization, the ATC, had operated since the end of the war.

Domestic aeromedical evacuation, which had continued in the postwar period using C–54s and C–47s, now had to use greater numbers of the C–47s during

the Berlin crisis. At the conclusion of the Berlin airlift, the Secretary of Defense

issued a directive that aeromedical evacuation would be used for military patients

whenever possible. This helped draw attention to some of the deficiencies of the

unmodified transport that had been the standard vehicle for moving patients.72 The

result that the Air Force acknowledged for the first time since the days of the CoxKlemin air ambulances in the 1920s was that a need existed for specialized

aeromedical evacuation aircraft. A modification program was established for

twenty-four C–47s to improve the cabin heating system, install easily cleanable

floor coverings, and construct a heat-conserving bulkhead between the patient

area and the cargo doors. Similarly, some thirty C–54M four-engine aircraft were

modified to make them more comfortable and functional, dedicated to aeromedical evacuation missions. The added emphasis given to aeromedical evacuation

helped create a stronger constituency for the mission within MATS. Supervision

was vested in the command surgeon, Col. Wilford Hall, and an aeromedical evacuation division was established to coordinate the function.73 A large number of

transport aircraft developed during the war had been modified to carry patient litters, and gradually some began to enter the Air Force inventory in the postwar

period.

Neglected in these developments was the use of aircraft for the evacuation of

the wounded and sick from the front lines. This function had been a significant

element of David Grant’s thinking in 1940. Frontline evacuation had been exercised widely during the war on an emergency basis using light aircraft which had

been allocated for other missions. General Arnold and his staff had resisted the

idea of developing a formal capability for air ambulances because they considered

it would divert resources from building a bomber-oriented combat force, but it did

not prevent the Army air observation artillery units and AAF liaison squadrons

from doing excellent ambulance work in all theaters, particularly in the Pacific.74

As a result of the success of the Army air observation artillery posts using

light aircraft, General Eisenhower pressed the AAF to allow expansion of the

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Army’s use of light aircraft for other ground force missions under control by

Army ground commanders. Reluctant to deviate from AAF doctrine over centralized control of airpower by AAF commanders, Arnold and the AAF gave in when

Eisenhower, now understood to be Marshall’s successor as Army chief of staff,

predicated his support for an independent air force after the war on an expansion

of organic Army aviation—aircraft under ground commanders’ control. As

Arnold’s deputy AAF commander, Ira Eaker came to an agreement in late July

1945 with Commander of Army Ground Forces Gen. Jacob Devers in which the

AAF officially countenanced a substantial increase in the number of liaison aircraft organic to various types of ground combat forces like tank battalions, cavalry divisions, infantry and mountain divisions, and to technical services like the

engineers. Shortly thereafter, the distribution of liaison aircraft was extended to

Army medical units.75

The AAF had not been enthusiastic about subsequent rumors that the Army

was going to organize liaison squadrons for aeromedical evacuation, and Grant

noted in his diary that the AAF now regretted letting the Army assume the air

observation function.76 The AAF did not itself pursue development of a specific

frontline aeromedical evacuation capability in the postwar period in spite of ongoing research into helicopter development, in which the air surgeon had shown

considerable interest. Helicopters had been used in the CBI theater for emergency

aeromedical evacuation in 1944, and although development and procurement of

light planes ceased after the AAF liaison squadrons were equipped in the middle

of the war, the air surgeon had pressed helicopter development for possible air

ambulance use.77

Helicopter development was still a subject of interest to the new Air Force.

Its priority for helicopters to equip its new air-sea rescue units led to conflict with

the Army over which service had responsibility for forward air evacuation. In the

Army, interest in frontline aeromedical evacuation continued, although the Army

was hampered by its controversy with the AAF and the loss of both pilots and liaison aircraft at war’s end. By the end of 1949, the Army had conducted successful

tests of the new Sikorsky YH–18 helicopter which was capable of transporting

two internal litters and a medical attendant. No development followed, nor was a

system or doctrine developed to govern its use.78 The Korean War would sharpen

the need to clarify the situation and would once again demonstrate the criticality

of mass aeromedical evacuation, even in the atomic age.

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A History of Aeromedical Evacuation in the U.S. Air Force
Chapter 5

THE KOREAN WAR AND THE EMERGENCE

OF THE MODERN AEROMEDICAL

EVACUATION SYSTEM

The Korean War was a true watershed. It would demonstrate clearly that even

in the shadow of atomic war, air evacuation of casualties still had relevance. On

the Korean peninsula, the U.S. Army demonstrated the courage and effective

command leadership that were key to overcoming the numerically superior forces

who lacked adequate training. In the air over Korea, the USAF reaffirmed the

decisive role of air superiority as the prerequisite for successful offensive and

defensive ground operations and the aeromedical evacuation of casualties.

The conflict would also reveal limitations on the readiness of the U.S. forces

and on the capability of aeromedical evacuation personnel and equipment to support them in combat. In both situations, a series of ad hoc measures succeeded in

overcoming these limitations, and in the latter case it provided the experience on

which the organization and procedures of the modern USAF aeromedical evacuation system were based.

The Korean War particularly served as the catalyst to refocus attention on the

value of the air evacuation of frontline casualties. Aeromedical evacuation, especially during the conflict’s critical moments, established the use of aircraft as essential for frontline casualty evacuation, and not just as a heroic means employed in

emergencies as it had been viewed by some Army surgeons during World War II.

Intra- and intertheater aeromedical evacuation demonstrated once again that air

evacuation was a more medically desirable and less costly means for moving

patients among medical facilities, and it served as a critical element in the logistic

support of U.S. forces in combat. The war would also demonstrate that aeromedical

evacuation could serve as an element in modifying the traditional chain of evacuation to make evacuation more rapid and efficient, medically and logistically.

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The rugged topography of the Korean peninsula and severely limited capabilities of the its road and rail systems were what made casualty evacuation by air

absolutely critical. This was particularly true during the period of relatively rapid

movement up and down the peninsula between the initial North Korean attack and

the emergence of the essential stalemate two years later. Japan served as an offshore COMZ, much as England had done during World War II, with U.S. Army

hospitals located in a number of cities, but Japan possessed neither the same logistic stockpiles nor reservoirs of U.S. manpower for deployment that were available

in England in 1944.

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South Korea had only two widely separated seaports of any consequence, and

its road and rail networks were relatively poor. The Far East was thousands of

miles from the sources of U.S. manpower and supplies. Airlift came into its own

by demonstrating its value for deploying and logistically supporting fighters in

fast-moving conflicts in which there was neither time nor the means to amass the

heavy ground- or sea-based logistic tails that had served U.S. forces so well in

World War II. This recognition and the consequent growth of troop carrier and

MATS airlift capabilities became linked to the development of aeromedical evacuation systems, and in 1948 the JCS directed that the Air Force establish such systems for the Army and for its own forces. The experience of the Korean War and

the larger defense budgets stimulated by the war and the U.S. commitment to the

North Atlantic Treaty Organization (NATO) would generate the development of

these systems in earnest.

Aeromedical Evacuation on the Eve of War

Aeromedical evacuation by the USAF at the beginning of 1950 was still

essentially oriented toward moving patients during peacetime. As experienced

observer Richard Meiling, formerly from the air surgeon’s wartime office and

now chairman of the Armed Forces Medical Policy Council, noted, “as a peacetime operation, the air transportation of patients is steadily improving in efficiency. As a military operation under combat conditions, a lot of improvement is still

required.”1 Troop carrier aircraft, supplemented on occasion by MATS aircraft,

moved sick and injured occupation troops to theater medical facilities. Longrange MATS aircraft, still chiefly C–54s, transported patients who required treatment unavailable in theater medical facilities to the CONUS, and they helped the

shorter range C–47s move patients from the ZI ports of entry to general hospitals

or convalescent centers within the United States. The end of the Berlin blockade

in 1949 had permitted reassigning C–54s to MATS and replacing some of the

C–47s in the domestic aeromedical evacuation system with the larger C–54 aircraft. On the eve of the Korean War, MATS was providing aeromedical evacuation for approximately 350 patients monthly from Tokyo to the United States.

Intratheater aeromedical evacuation in the Far East was provided by transport aircraft manned by personnel from the 801st MAES attached to the 374th Troop

Carrier Wing at Tachikawa AB in the Tokyo area.2

Presumably stimulated in part by the Secretary of Defense’s directive that

military patients should be moved by air whenever possible, the USAF surgeon

general, Maj. Gen. Harry Armstrong, in November 1949 had pressed successfully to have a number of C–54s modified to better equip them to provide aeromedical evacuations. Beginning in January 1951 the first of thirty modified C–54Es

were delivered with a galley, nurses’ storage cabinets, and a cabin ventilation system that operated while the aircraft was on the ground to keep patients comfortable while awaiting flight. Redesignated as MC–54Ms, the last aircraft was deliv105

The Korean War and the Modern Aeromedical Evacuation System
ered in January 1952. Later, ten C–97 pressurized transports were similarly reconfigured and delivered as MC–97s in February 1951.3 The MC–97C variant could

carry up to seventy-nine casualties with a crew of four medical attendants.

MATS exercised centralized control of aeromedical evacuation personnel

through three aeromedical evacuation squadrons, each assigned to one of the three

MATS divisions: Atlantic, Pacific, and Continental. This geographic distribution

provided support to U.S. forces in the European and Far Eastern theaters, while

also supplying patient airlift within the ZI through the Continental Division. In the

Pacific, aeromedical evacuation flights were supported by the 1453d MAES headquartered in Hawaii, with a detachment at Tokyo’s Haneda airport. Intra- and

intertheater aeromedical evacuations were now generally routine. The largely ad

hoc procedures for conducting aeromedical evacuation developed during World

War II had been extended and adapted to the much smaller requirements generated by the postwar military force, much of which was engaged in occupation duties

in Germany and Japan. Exchanges of equipment, including blankets and litters;

communications among the dispatching and receiving medical facilities, inflight

medical teams, and aircrew; and transmission of diagnostic and treatment information regarding patients, all were accepted procedures, although they were not

accomplished without occasional glitches.

Research sponsored by the School of Air Evacuation now collocated with

SAM at Randolph Field, Texas, did relate to wartime requirements, but it was not

directed primarily toward aeromedical evacuation. Constrained for funds like the

rest of the Air Force, SAM nevertheless developed an air-transportable hospital

(ATH) that could be carried by a C–47. It was also involved in development of the

XC–120.4 This experimental aircraft was a variant of the C–119, the medium

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C–54s were commonly used for aeromedical evacuation from Korea.
troop carrier aircraft that during the course of the Korean War became the Air

Force’s workhorse medium transport aircraft. The XC–120 fuselage was designed

so that the lower half was actually a detachable pod able to be configured for 36

litter or 44 ambulatory patients. Although the C–120 never got beyond the experimental stage, its use as a small patient-holding facility was a possible application.

The noise and vibration that made the Air Force medical service deem the C–119

undesirable for aeromedical evacuation may have influenced the decision not to

build more than the prototype. As an air ambulance, it would have been comparable to but no better than the C–119, which could be configured for 35 litter and

67 ambulatory patients.5

Neither aeromedical evacuation nor field medicine in general was a primary

issue engaging the Army surgeon general before June 1950. Staffing problems in

the medical department that had plagued it since the exodus of wartime doctors

was exacerbated by the separation of the Air Force Medical Service in 1949, when

Army doctors were given the opportunity to opt for service in the Air Force.6 The

professionalization of the Army Medical Department pushed by General Kirk and

his successor Gen. Raymond Bliss continued, reflecting the Army’s persistent

need to make the Medical Corps attractive to young doctors. One senior medical

department officer, arguing against what he saw as inadequate attention being

paid to training medical officers in things military, quoted an unnamed medical

leader of the recent war as saying, “it was now considered almost indecent for a

doctor to serve with troops!”7

Both the Army and new Air Force Medical Service were restricted by the

tight defense budgets allocated to their parent services by Secretary of Defense

Forrestal’s successor, Louis Johnson.8 The medical services were also having to

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Casualties being transferred from an H–19 to a C–54.
prioritize, to allocate scarcity as it were, among their various elements, while trying not to compromise unduly their primary mission of providing for the health of

their parent forces.

An early casualty of the constrained budgets was the organic air ambulances

assigned to the Army Medical Department. Authorized during General

Eisenhower’s tenure as army chief of staff, their priority had been greatly reduced

after the severe drawdown of Army aviation with demobilization and postwar

budget cuts. Contention also arose between the Army and the newly independent

Air Force over who had responsibility for forward casualty evacuation.9

War and Aeromedical Evacuation on the Korean Peninsula

On June 25, 1950, the North Korean army in overwhelming force entered

South Korea, crossing the 38th parallel which served as the political divide

between the communist Democratic Peoples Republic of Korea and the U.S.-supported Republic of Korea (ROK). Infantry units spearheaded by Soviet-built T–34

tanks were opposed by South Korean forces, from which tanks, antitank weapons,

and artillery heavier than 105-mm caliber had been deliberately withheld by the

United States to preclude attacks on North Korea by the highly nationalistic and

anticommunist South Korean president, Syngman Rhee. At the time of the North

Korean attack, approximately half of the ROK army vehicles were out of commission, and it had only a six-day reserve of ammunition.10 Initially, the South Korean

forces inflicted heavy losses on the invaders, but its forces soon began to collapse.

President Truman’s decision to support South Korea against the aggression, first

with air and sea forces and then with U.S. ground forces, meant that U.S. troops

drawn from the four understrength divisions occupying Japan would have to be

sent into combat quickly to try to stem the rapid North Korean advance.11

U.S. troops would enter combat with several severe handicaps. The occupation forces comprising the 24th, 25th, and 7th Infantry Divisions and the 1st

Cavalry Division were manned largely by young draftees whose level of combat

readiness was low due to lack of training. All but one of the collective twelve

infantry regiments of these divisions had only two instead of the usual three

infantry battalions, and the artillery battalions had only two of the normal three

firing batteries. Overall, the divisions averaged approximately 70 percent of full

war strength.12

Task Force Smith, the first U.S. unit hastily deployed by troop carrier C–54s

from Japan to enter combat in Korea, was plagued by materiel shortages. It went

into action on July 5 with only six antitank rounds for its six 105-mm howitzers

because the Army had given priority to Europe for the small number of howitzer

rounds it had procured. These would prove to be the only effective ground-based

weapons against the North Korean T–34 tanks as Smith’s force was effectively

brushed aside by the tank-led North Korean infantry. Before retreating, Task

Force Smith suffered more than 30 percent casualties.13

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Air evacuation of U.S. personnel had begun even before the President’s decision to intervene. C–54s and C–47s had been called upon to assist in evacuating

Americans from the embassy and those serving with the Korean Military

Assistance Group, as well as foreign nationals including members of the United

Nations Commission on Korea, when the rapidity of the North Korean advance

on Seoul created an emergency. The imminent fall of the South Korean capital

made continuing the evacuation of U.S. dependents and others by sea from Inchon

impractical. Air evacuees were flown from Kimpo and Suwon airfields near Seoul

to Itazuke, Japan, across the Korean Strait from Pusan. During the course of providing air cover for these evacuations, fighters from Fifth Air Force had successfully destroyed a significant portion of the North Korean air force, and it soon

established the air superiority over the peninsula that it was to maintain throughout the war.14 This air superiority became a prerequisite for the aeromedical evacuation of casualties after U.S. ground troops entered the conflict.

The initial North Korean attack resulted in a fighting retreat by South Korean,

U.S., and other forces fighting under a UN flag. They regrouped in an enclave in

southeastern Korea where they remained until mid-September 1950. Following an

amphibious landing by the new U.S. X Corps at Inchon on the western coast of

South Korea on September 15, 1950, the now much-strengthened Eighth Army

broke from the enclave, and the combined UN forces then essentially destroyed

the North Korean army as a fighting force, forcing it from South Korea within two

weeks. Using a UN resolution as justification, UN forces then invaded North

Korea in early October with the Eighth Army moving forward in the western half

of North Korea, and the X Corps entering the eastern half after making an

amphibious landing at Wonsan on North Korea’s east coast, some eighty miles

north of the 38th parallel.

In spite of the arrival of heavy winter conditions, the two forces operating

essentially independently of one another moved rapidly northward toward the

Yalu River until late October, when massive Chinese intervention once again

forced them to retreat. This much more difficult retreat ended in early January

1951 at lines stabilized approximately forty miles south of Seoul. From there, UN

offensives by late June 1951 had gradually pushed the communist forces north

above the 38th parallel, and both sides began to explore an armistice. Talks began

in July 1951 and lasted for two years until an armistice was signed on June 23,

1953. Fighting continued during these talks, generating casualties and requirements for aeromedical evacuation, which, by the end of the war, was being

accomplished smoothly and efficiently.

Many factors early on made aeromedical evacuation essential to the prosecution of the war. The combination of Korea’s geography and climate, the communist tactics of creating roadblocks and infiltrating behind the UN forces along the

valley ridges, the rapidity of advance of both communist and UN campaigns when

on the offensive, and the effect of the air interdiction campaign by Fifth Air Force,

Navy, and U.S. Marine air units and the Bomber Command of the Far East Air

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The Korean War and the Modern Aeromedical Evacuation System
Force (FEAF) in disrupting the Korean road and rail systems created situations in

which casualty evacuation could be effected only by air. The needs in the field for

ammunition, medical supplies, and food for U.S. and other UN forces could be

fulfilled only by airlift or airdrop. In many cases, emergency aeromedical evacuation could be accomplished only by helicopter.

The first phase of the Korean conflict was marked by the success of the

North Korean army in forcing ROK, U.S., and other UN forces by mid-July into

the so-called Pusan Perimeter. This was a rectangular enclave in extreme southeastern Korea, roughly 100 miles long north to south, and about 50 miles east to

west. The port of Pusan lay midway across the enclave’s southern boundary, and

the Naktong River anchored it on its western side. The area included two airfields, one outside Taegu, which was Headquarters Eighth Army, the other was

east of Pusan.

Aeromedical evacuation was used basically only as an emergency means for

moving casualties during the initial phase of the war. In early July, as the first U.S.

ground units were going into action, General MacArthur’s air commander, now

Lt. Gen. George E. Stratemeyer, had informed MacArthur that FEAF was prepared to evacuate casualties by air from the peninsula using return flights of aircraft bringing in supplies and men to Korea from Japan. Several days before, the

Korean Military Assistance Group had requested that three sick men be evacuated from Taejon in central Korea, and they were evacuated to Japan by a C–47 of

the 374th Troop Carrier Wing.

During these initial weeks as the Eighth Army retreated south, twin-engine

C–47s and C–46s were used to move the heavy volume of men and equipment

into Korea because the airfields still available on the peninsula could not accommodate larger aircraft like the C–54s.15 Personnel and materiel originating in the

Tokyo area and destined for Korea were flown by C–54s of the 374th Troop

Carrier Wing from Tachikawa AB to Ashiya on the southernmost Japanese island

of Kyushu, just across the Korea Strait from Pusan, where they were reloaded

aboard the smaller aircraft. This two-phase airlift pattern was soon applied to the

movement of casualties.

Aeromedical evacuation from Korea began officially on July 7 using 801st

MAES air evacuation teams relocated to Ashiya from Tachikawa AB. Teams

attended patients on troop carrier aircraft returning to the air base at either Ashiya

or nearby Itazuke from the combat airfields at Taegu, Pohang, Taejon, and Pusan.

From these fields, evacuees were transported to the Army’s 118th Station Hospital

at Fukuoka. Itazuke’s location at Fukuoka made it the predominant destination for

casualties flown from Korea.16

Because the C–54s were generally returning to Tachikawa empty, this retrograde airlift very quickly began to be used to move patients attended by teams

from the 801st from Fukuoka to specialized hospitals at Osaka and elsewhere in

Japan. Because these intra-Japan patient airlifts were generally arranged by the

dispatching hospital twenty-four hours in advance, the system resembled the

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A History of Aeromedical Evacuation in the U.S. Air Force
scheduled nature of domestic aeromedical evacuation. Patients being sent to the

United States for further treatment were ultimately moved to the Haneda airport

where the MATS terminal was located.17

The 374th C–47s could move patients from Pusan to a modern hospital in

Japan in an hour. The alternative mode of casualty evacuation from Korea was by

ship from Pusan, which took several days. From July 7 to September 15, when the

Inchon amphibious landing occurred and the Eighth Army’s breakout from the

Pusan Perimeter began, the 374th Troop Carrier Wing evacuated 3,855 casualties

from Korea. Another 9,160 were evacuated by surface vessels. Empty transport

aircraft could have carried as many as 36,000 patients to Japan during the same

period. One reason the Eighth Army had not used aeromedical evacuation more

was its preference for retaining ground force casualties in Korea when possible.

The Eighth Army surgeon estimated that nine of ten soldiers could be returned to

duty without leaving Korea, but that patients transported to Japan would take at

least thirty days to return to their units after hospitalization.18

The surgeon was also reacting to the imperfections of the ad hoc aeromedical

evacuation system and expressing residual concerns with having to rely on retrograde airlift. During the summer battles, the Eighth Army had chosen to send its

casualties from the Mobile Army Surgical Hospital (MASH) at Taegu City by

train south to the evacuation hospital at Pusan. This was a conscious choice not to

airlift them from Taegu AB, eight miles from the city, because of the shortage of

motor ambulances and poor roads connecting them. Located some distance from

the evacuation hospital in Pusan City, the air base at Pusan had no holding facilities, which made evacuation by air somewhat problematic from the point of view

of patient welfare if evacuation was dependent on retrograde airlift.19

The surgeon’s interest in using aeromedical evacuation for frontline casualties was considerably greater. The Air Force’s 3d Air Rescue Squadron at Ashiya

was equipped with L–5 liaison aircraft and H–5 helicopters, which its commander was willing to use for emergency casualty evacuation even though his official

mission was to search for and rescue downed airmen. The L–5 had been used for

frontline evacuation on an informal basis during World War II, particularly in the

Philippine campaigns, and helicopters were used successfully for aeromedical

evacuation during this period although their actual use was limited to a handful of

cases due to their relative scarcity.20

Service interest in helicopters continued in the postwar era, but it was constrained by tight budgets and more basic struggles over roles and missions.

Distinguishing the role of Army aviation from that of the now-independent Air

Force was one of these struggles, and the JCS in May 1949 directed the Air Force

to establish evacuation systems for the Army and for itself. In September 1949 it

reaffirmed that “responsibility for the air evacuation of patients continues to be

vested in the Department of the Air Force.”21 The Air Force had not addressed the

issue of frontline evacuation before the Korean War, and it did not envision its air

rescue squadrons in such a role.

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Helicopters were perfect for aeromedical evacuation in the rugged terrain and

rice paddies where the fighting was occurring in Korea. H–5s could lift a patient

and a technician plus two passengers in externally attached pods. The Army had

no helicopters in the theater, although some Army medical officers (chief among

them, Spurgeon Neel) had expressed enthusiasm about tests using a Sikorsky

YH–18 helicopter for aeromedical evacuation conducted in November 1949 at

Fort Bragg, North Carolina.22

The L–5s of the 3d Air Rescue proved to be ineffective due to the Korean

topography. However, a detachment of H–5s sent to Taegu from Ashiya on July

22, 1950, soon demonstrated the worth of helicopters for evacuating casualties in

emergency situations. The North Korean tactic of infiltrating around and enveloping UN forces as they traversed roads during the long summer retreat often temporarily isolated U.S. or ROK troops. The helicopter’s ability to land and take off

without requiring a landing strip made it uniquely valuable in situations when

friendly troops were surrounded or otherwise inaccessible by ground transport.

Mixing air rescue activities with responses to Army requests for emergency

aeromedical evacuation, the half dozen H–5s had evacuated eighty-three solders

by August 29, many of whom were suffering from wounds that would have killed

them during the ten or more hours a motor ambulance would have required to

deliver them to a field hospital, according to the Eighth Army surgeon.23

These early demonstrations of helicopter effectiveness by the Air Force elicited positive reactions from Army and Air Force leaders in the theater and brought

to a head the issue of which service would have responsibility for frontline evacuations. In October, Army Surgeon General Bliss requested, with the strong support of theater commander General MacArthur and his surgeon, General Hume,

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The Sikorsky H–5 (foreground) was often used to carry casualties in Korea.
procurement of helicopter ambulance companies consisting of twenty-four helicopters each. Before the end of the month, helicopters were being purchased for

immediate airlift to the Far East, and four detachments of four helicopters each

were being activated for medical use.24

The reaction of General Stratemeyer, commander of MacArthur’s FEAF, was

equally positive. In mid-August, he requested that USAF headquarters in effect

create a USAF helicopter aeromedical evacuation service. He asked for the organization and dispatch to Korea of an Air Force evacuation and utility squadron

with twenty-five H–5 helicopters, a flight surgeon, and medical technicians.25

Although USAF headquarters was negative to Stratemeyer’s request, it did dispatch fourteen additional H–5s to be assigned to the 3d Air Rescue Squadron,

observing that USAF planning for aeromedical evacuation had “not included the

U.S. Army function of evacuation from frontline battle stations.”26

Army helicopter aeromedical evacuation was officially established on

January 1, 1951, when the 2d Helicopter Detachment became operational. In the

pattern that would be followed, it was assigned to the 8055th MASH. More Army

helicopter units followed, and aeromedical evacuation of casualties by Air Force,

Army, and then Marine Corps helicopters became a regular element in the evacuation chain. Because of their small numbers, the helicopters were generally

requested only for the most seriously wounded who needed the quickest medical

attention possible to save their lives.27

With airlift having proven to be an essential element in both the logistics and

medical support of the UN forces on the peninsula, the Far East Command (FEC)

moved quickly to improve the efficiency of the first effective but undoubtedly

wasteful use of the available transport aircraft. The Berlin airlift had demonstrated how centralized control of available airlift resources could best support a mission, and FEAF quickly sought to replicate the system for the Japan-Korea airlift.

The former commander of the Berlin airlift, Air Force Maj. Gen. William Tunner,

was brought to Japan and on August 26, 1950, given command of the new FEAF

Combat Cargo Command (after January 25, 1951, it became the 315th Air

Division [Combat Cargo]) specifically to handle paratroop operations during the

planned Inchon invasion.28 The processes and procedures he caused to be established not only benefited combat organizations in Korea that required rapid logistic support, they also provided a rational framework for aeromedical evacuation.

Eighth Army surgeons could accept aeromedical evacuation as a routine rather

than as an emergency operation, given the ability to coordinate airlift supplying

forces in Korea with returning airlift to carry patients back to definitive care in

Japan or the ZI.

Tunner established a mechanism for deciding the degree to which requests by

each major user (Army, Navy, or Air Force) of airlift should be assessed in light of

available airlift capability. At his suggestion, the FEC Air Priority Board representing the three services took responsibility for allocating among them portions of

the airlift capability that Combat Cargo specified to the board each week, the deter113

The Korean War and the Modern Aeromedical Evacuation System
mination being based on the tactical situation and the amount of airlift available.

Liaison officers from the two principal users, Eighth Army and FEAF, comprised

the Joint Airlift Control (JALCO) located at Combat Cargo headquarters at Ashiya.

They received specific requests for air transportation from their services and decided what was to be moved and with what priority, keeping the consolidated requests

within the total tonnage allocated to each service. The Transport Movement

Control at Ashiya then scheduled aircraft to fill the requests, issued orders, monitored the missions, and diverted or canceled missions by radio, if necessary. The

success of this system was aided considerably by the arrival of additional troop carrier aircraft including a wing of the new C–119 medium transports.29

By September 1950, after discussions with Eighth Army surgeons, Tunner had

integrated aeromedical evacuation into the airlift system. The 801st MAES commander, Lt. Col. Allen D. Smith, also dual-hatted as Combat Cargo surgeon,

became responsible for aeromedical evacuation. Each day at noon, Army medical

evacuation officers in Korea and Japan communicated to Smith’s office the

requirements for patient movement the next day, and his office submitted a consolidated request to Transport Movement Control scheduling the requisite airlift.

Aeromedical evacuation teams from the 801st were included as necessary. To the

maximum degree possible, aeromedical evacuation requests were fulfilled on

return flights of supply aircraft. The efficiencies made possible by the centralized

control of airlift in the theater allowed special aeromedical flights to be scheduled

to meet Eighth Army’s requests at virtually all times. This structured approach and

Combat Cargo’s continuous field liaison during September and October 1950,

combined with the remarkable swings in the tactical situation that increased the

number of casualties, helped make aeromedical evacuation a standard method for

transporting the sick and wounded, rather than serving in only an emergency mode.

Evacuations by air from Korea jumped from 335 in August to 5,890 in September,

while the number of sea evacuations dropped from 4,459 to 2,171.30 Although not

in accord with nascent Air Force doctrine, the Army ran the holding facilities at the

evacuation points as Colonel Smith requested; he argued that the Army should take

responsibility because the Air Force did not have sufficient personnel.31

The patterns of aeromedical evacuation established in the autumn months of

1950 generally persisted through subsequent phases of the war. By the end of

1951, virtually no patients were evacuated by sea from Korea.32 Eighth Army surgeons recognized that casualty evacuation by air provided greater flexibility for

medical regulators who determined where patients should be sent, and it made the

chain of evacuation more responsive to changes in the tactical situation. To evacuate expected casualties during the Inchon landing and the Eighth Army breakout

from the Pusan Perimeter, C–54s were dispatched to Kimpo AB close to Seoul as

soon as the airfield was retaken. In the drive into North Korea, Combat Cargo

established an intra-Korea airlift system to fly the sick and wounded from captured North Korean airfields to newly established field hospitals on the peninsula

or to transport them to aerial ports of embarkation for flights to Japan.

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In early October, Tunner had tried unsuccessfully to convince the Eighth

Army surgeon that patients should be airlifted directly to hospitals in Japan rather

than be moved point-to-point in Korea and then aeromedically evacuated to

Japan. The surgeon still wanted to keep as many people in Korea as possible, so

Tunner established a daily intra-Korea C–47 aeromedical flight from Suwon to

Pusan, where patients were screened for disposition at the 8054th Evacuation

Hospital. Retaining in Korea the wounded or sick who could return to the line

within a reasonable period of time would loom all the more important by the

spring of 1951 when the JCS made it plain to the new Eighth Army commander,

Gen. Matthew Ridgway, that he could expect to receive no additional forces, only

individual replacements for his losses.33 Meanwhile, 801st evacuation teams of

flight nurses and technicians were flying into Sinanju, some fifty-five miles south

of the Yalu River, to provide inflight medical care during the trips southward to

the 8055th MASH in the former North Korean capital of Pyongyang.34 Until the

fortunes of war changed and communist forces recaptured the northern airstrips,

801st personnel continued to assist in evacuating casualties.

In the winter retreat after the Chinese intervened in late November, airlift

became the only means in many cases to evacuate casualties from advanced positions. Perhaps the most dramatic such episode occurred in December at the

Changjin Reservoir, only seventy miles from the Yalu River. X Corps elements,

including U.S. Marine and Army units, ROK troops, and British marines had

reached the reservoir by difficult mountain roads but then found themselves surrounded by Chinese forces. The terrain was extremely rugged, and movement and

fighting were hampered by frigid temperatures and heavy snow. The Chinese had

put troops onto the snow-covered hills and mountains about the reservoir and

erected twenty-four roadblocks on the only ground supply route, the winding and

mountainous road leading to Hungnam and Hamhung on the east coast.35

The UN position quickly became untenable, with retreat to the sea the only real

option. The evacuation by air of X Corps casualties from two enclaves at Hagaru-ri

and Koto-ri near the reservoir permitted the remainder to fight their way back to the

coast and be evacuated successfully by sea. C–47s from the 374th Wing’s 21st

Troop Carrier Squadron including a detachment from the Royal Hellenic Air Force

conducted the evacuation, operating from tiny airstrips that were literally bulldozed

out of the frozen ground. In five days they shuttled 4,689 sick and wounded men to

the former North Korean airstrip at Yonpo. The most critical casualties were flown

to safety in Japan in C–54s and Marine Corps R5Ds (the Navy designation for the

C–54), while others were sent to Army and Marine Corps field hospitals in

Hungnam or to the Navy hospital ship USS Consolation moored in Hungnam

Harbor.36 The aeromedical evacuees sent to Japan were attended by flight nurses

from the 801st who had been held at Yonpo because of the danger inherent in the

shuttle operation; 801st medical technicians accompanied the C–47 shuttle flights.37

Helicopters of all the services continued to demonstrate their value during the

retreat; during the spring UN offensive that generally established what would

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become the truce line; and during the relatively static period that persisted until

the fighting ceased in July 1953. Marine Corps helicopters assisted with the evacuation of casualties during the withdrawal from the Changjin Reservoir, and it was

a Marine Corps initiative that resulted in the installation of platforms on hospital

ships enabling them to serve as floating hospitals. After USAF headquarters

refused General Stratemeyer’s request to form an Air Force helicopter medical

evacuation unit, 3d Air Rescue organized its helicopter detachment in Korea as

Detachment F at Taegu in September 1950 and gave it a combined air rescue and

aeromedical evacuation mission. The detachment followed the fighting north after

the breakout from Pusan, moving from Pusan to Taegu, to Seoul, and to

Pyongyang before returning south after the Chinese intervened.

To utilize the few helicopters available, one or more were attached to MASH

units to pick up only the most seriously wounded, a procedure followed by Army

helicopter units after they began operations at the beginning of 1951. Helicopters

also proved invaluable for retrieving paratroop casualties from drop zones, as they

did after drops at Sukchon and Sunchon in North Korea in late October 1950. In

February 1951, at the high point of the Chinese communist winter offensive, 3d Air

Rescue’s H–5s evacuated fifty-two badly wounded soldiers from the surrounded

village of Chipyong-ni, which was the hinge of the Eighth Army’s defense line

south of Seoul, after they had delivered badly needed medical supplies. Although

Army helicopter operations came to dominate medical evacuations as the war progressed, in the spring of 1951 the H–5s and one new YH–19 helicopter of 3d Air

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The H–19 was often used to ferry wounded soldiers.
Rescue’s Detachment F were still performing 85 percent of the frontline patient

pickups. As of February 20, 1951, Air Rescue Service helicopters had evacuated

750 critically wounded soldiers, half of whom would have died had they been

moved by ground transportation, according to the Eighth Army surgeon.38

The flexibility inherent in the aeromedical evacuation capability of the 315th

Air Division also helped the theater medical establishment provide better definitive care for evacuees. This flexibility enabled the Japan Logistics Command

(JLCOM) to allocate patients among an increasing number of Army hospitals

being constructed or expanded in Japan. The JLCOM regulating officer could thus

optimize the use of available space and medical personnel and respond effectively to surges in the flow of casualties arriving from the peninsula.39 More important medically for the patients was the ease of transporting them speedily and safely without the negative impact of uncomfortable travel by train or ambulance. The

flexibility gained within the regulating system facilitated the development of specializations within the JLCOM hospital system, with ultimate benefit to the

patients. Specialists could be concentrated with equipment and drugs appropriate

to their specialty, and patients could be brought to them.40

After late January 1951, casualties from Korea were categorized into three

groups for treatment: those with head, chest, and eye injuries were flown directly

to the Tokyo area for specialized surgery; those with frostbite and hepatitis were

flown to Osaka, where specialized treatment centers had been established for

these problems; all other types were distributed according to available bed space

throughout Japan. This selection process merged with the so-called tri-entry system requested by JLCOM intended to simplify movement within Japan by flying

directly to Tachikawa AB for the Tokyo area, to Itami AB for Osaka, or to Itazuke

AB for Fukuoka. Patients were allocated to these destinations on a 40/40/20 basis.

Both procedures meant that a patient could be regulated rapidly to the appropriate

specialists for definitive treatment, or identified readily for aeromedical evacuation to the ZI on the basis of his or her projected recovery time, compared to the

then-current evacuation policy which for FEC was generally 120 days. Except for

emergency evacuations, the Army in Korea still insisted that patients go through

all the steps of the traditional chain of evacuation.41

By the end of hostilities in 1953, 315th Air Division and the theater-based airlift organizations that preceded it had aeromedically evacuated 311,673 sick and

wounded patients while MATS had moved 43,196 patients to the United States.

This number was actually greater than the total number of casualties suffered during the conflict because it includes patients moved multiple times within Korea,

between Korea and Japan, and within Japan. The benefits of aeromedical evacuation compared with the ground transportation of patients were manifest to all,

reaffirming for the most part the advantages that casualty evacuation by air had

provided in World War II. Not least was the positive effect on the morale of a

wounded or sick soldier or marine who was quickly lifted from the combat environment to leave the stench and heat of battle behind.

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Even for helicopter frontline evacuation, movement by air was generally

more comfortable than transportation by motor ambulances over poor roads or by

ships that generally were not air-conditioned.42 Medically, patients benefited from

less handling, the speed with which they reached definitive care, and the ability to

receive medication, including blood plasma, in transit. Beyond the question of

greater comfort was the avoidance of further injury incurred from being jolted on

the rough roads of Korea. Logistically, aircraft provided a means for rapid medical resupply; it could also reduce the support needed by patients and the attending medical staff by keeping evacuation hospital populations low. The ability to

evacuate patients readily by air to Japan in December, against the possibility that

Chinese forces might overrun South Korea, also provided a strategic advantage.43

The death rate for casualties who reached hospitals in Korea (2.4 percent)

was approximately half that suffered by the same category of wounded in World

War II (4.5 percent). Actually, as Gen. Spurgeon Neel, the Army physician perhaps most responsible for pushing aeromedical evacuation within the Army

Medical Department, argued convincingly long after the Korean War, Army medicine was a great deal better than even these figures suggest. The 2.4 percent death

rate included patients who died shortly after reaching Army medical facilities but

who during World War II would have been left to die on the battlefield because

their wounds were so severe that they could not have been transported to a hospital in time to even attempt medical intervention. Such World War II fatalities

would have been counted as killed in action.44 As early as October 1951, in a

speech to the Association of Military Surgeons, Army Surgeon General Maj. Gen.

George Armstrong acknowledged that aeromedical evacuation had contributed

greatly to the saving of lives.45

The Air Force Attempts to Institutionalize the Aeromedical

Evacuation Lessons of Korea

The essentially ad hoc aeromedical evacuation system developed by the U.S.

Army and General Tunner’s 315th Air Division was given official sanction by

issuance of a FEC directive on December 18, 1951.46 At Headquarters USAF, the

surgeon general’s office sought to incorporate the lessons drawn from Korea into

an aeromedical evacuation system that it acknowledged, with the exception of

MATS operations, had been found lacking in many respects. The most urgent

need it saw was developing a concept for forward aeromedical evacuation.47

The Air Force’s new approach to theater aeromedical evacuation system was

embodied in a 1951 manual that laid out a comprehensive organization for forward air evacuation, complete with tables of organization and equipment

(T/O&Es) for each element. These were the Forward Medical Air Evacuation

Flight (T/O&E 1–4101T EA), and three aeromedical evacuation holding groups,

designated as Heavy, Medium, and Light (T/O&Es 1–, 2–, and 3–4401T), which

were intended to receive and evacuate 400, 800, or 1,200 evacuees, respectively.

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These were to be organized on a cellular basis for inclusion in troop carrier wings,

as needed, and the manual detailed procedures for the operation of holding

groups. These additional functions and units were therefore grafted into the theater aeromedical evacuation system inherited from World War II and built around

troop carrier units. The new manual cited the need for a definite working priority

for aeromedical evacuation, although it conceded such a priority “would ordinarily be secondary to forward moving logistic activities, but nonetheless be a definite operational commitment capable of upward priority designation for separate

tactical situations.” It also noted the need to clarify how aeromedical evacuation

aircraft operating under instrument conditions should be treated. The manual

included a tabulation of the aeromedical evacuation characteristics of troop carrier aircraft and listed the new assault transports the Air Force was procuring. These

could operate on short, unpaved landing strips and could evacuate many more

casualties than the fixed wing L–5 liaison aircraft that the 3d Air Rescue was then

using in Korea.48

The Air Force’s new interest in incorporating frontline casualty evacuation

into its mission, which the AAF leadership had rejected in 1942, was already

hostage to the ongoing battle between the Army and the Air Force over the kind

and quality of the Tactical Air Command’s (TAC’s) support of the Army.49 The

Army’s Medical Department wanted the forward aeromedical evacuation mission

because of the demonstrated medical value of frontline evacuation by air, but the

command leadership also wanted the mission to prevent the Air Force from coopting the rotary wing aircraft they now began to perceive as having great potential for enhancing the combat arms.50 It was perhaps indicative that, when toward

the end of the war FEAF offered to take over the holding facilities the Army had

been operating in Korea, the Army refused to change the status quo.51

The linked issues of who was to control frontline aeromedical evacuation and

whether the Army would be given a free hand to develop rotary wing aircraft for

tactical purposes were resolved in favor of the Army in a series of joint exercises

and formal agreements at the service secretary level, even as the Korean conflict

progressed. A DoD memorandum in May 1949 had given responsibility for

aeromedical evacuation to the Air Force, which pursued developing its frontline

aeromedical evacuation in joint exercises in late 1951 and in 1952. For the

Southern Pine joint exercise held at Fort Bragg, North Carolina, in August 1951,

the Air Force had sought to demonstrate the superiority of moving casualties

exclusively by air to medical facilities in the rear rather than using a cumbersome

ground chain of evacuation—much as General Tunner and his surgeon, Colonel

Smith, had proposed at different times to the Eighth Army surgeon in Korea. The

aerial system proved so successful that on the ninth day of the maneuver the

infantry division suspended all ground evacuation activity except by the most forward echelon, the litter bearers.52

What was being demonstrated in the field was being undermined at the secretarial level. Frank Pace and Thomas Finletter, respectively the secretaries of the

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Army and the Air Force, although formally recognizing that “the Air Force is

assigned the primary function of supplying the necessary airlift to the Army,”

nonetheless signed an agreement on October 2, 1951, authorizing the Army to

possess its own organic aviation to perform a number of functions, including the

transportation of Army supplies, equipment, and small units within the combat

zone. The combat zone was defined as the area to the rear of the front lines

between 50 and 70 miles in depth. Moreover, the responsible Army commander

was authorized to use his organic aircraft “as he sees necessary for the discharge

of his mission.”53

In Operation Snowfall conducted in January and February 1952 the Air Force

found that the Army refused to allow casualties to bypass any links in the chain of

evacuation. In Operation Longhorn the Air Force discovered not only that its

evacuation activities were subject to greater restrictions but also that Gen. Mark

Clark, the Army commander, demanded that Army helicopters be allowed to perform aeromedical evacuation anywhere in the maneuver area and that he be

allowed to use them to resupply his tactical units. In the wake of Operation

Longhorn, the director of the Joint Airborne Troop Board recommended that the

Army unequivocally inform the Air Force that no requirement existed for Air

Force helicopter support in the combat zone.54

Obviously concerned more about strategic and tactical forces by this time, the

Air Force conceded the issue to the Army. Another Pace-Finletter agreement of

November 4, 1952, specifically authorized the Army to use organic aircraft for

aeromedical evacuation within the combat zone (now defined as “normally from

50 to 100 miles in depth”) “to include battlefield pickup of casualties, their air

transport to initial point of treatment and any subsequent move to hospital facilities within the combat zone.” The Air Force was also authorized aeromedical

evacuation from “the initial point of treatment or point of subsequent hospitalization within the combat zone” to points outside it as well as evacuation of casualties from the drop zone during airborne operations until ground linkup occurred.55

In spite of residual interest in pressing the Air Force case for frontline

aeromedical evacuation,56 the service by 1956 had conceded superiority in rotary

wing transport to the Army within the combat zone and had accepted the literal

interpretation of the Pace-Finletter agreement of November 1952. In January

1956, a joint Army, Air Force, and Navy manual, Medical Service in Joint

Overseas Operations, laid out the basic relationships governing aeromedical

evacuation in theaters of operation that remained in effect until the United States

entered the Vietnam War.

The manual assumed that a theater medical officer and a joint staff, including

a joint medical regulating office, would provide general medical policy to all the

service theater components. Aeromedical evacuation responsibility was to be distributed among the services along the lines of the 1952 Pace-Finletter agreement.

The Army and Navy would be responsible for picking up battlefield casualties in

their respective combat zones (the Navy also had responsibility for Marine Corps

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combat areas) and for transporting them to initial points of treatment or any subsequent medical facilities elsewhere in the combat area.

The Air Force was responsible for aeromedical evacuation from within the

theater area to the CONUS or a designated temporary safe haven other than one

provided by the Army or Navy within its combat zone. As specified by the PaceFinletter agreement, the Air Force also had responsibility for all evacuation from

initial points of treatment or points of subsequent hospitalization within the combat zone to points outside the combat zone. The Air Force was also made responsible for providing in-transit and staging facilities for evacuees and for attaching

casualty aeromedical evacuation control officers to serve as liaisons with Army

and Navy regulating agencies.

In the years remaining before the United States once again found itself at war

in Asia, aeromedical evacuation tended to be determined more by developments

in airlift, both tactical and strategic, than by other factors. TAC sought to develop

the theater aeromedical systems within the parameters that the Pace-Finletter

agreements had specified. TAC’s troop carrier air force, the Eighteenth, developed

a complete concept of a tactical aeromedical evacuation system (TAES) that

USAF headquarters approved in March 1955 and which assumed utilizing assault,

medium, and heavy troop carrier wings. Now free to develop helicopter aviation

for tactical purposes, the Army also accepted the necessity for casualty evacuation

by air.57

The Effect of Korea on Strategic Airlift

and Aeromedical Evacuation

MATS was called upon to provide a much expanded intertheater airlift to support the Korean conflict logistically while also contending with unexpected surges

in transpacific aeromedical evacuation. This activity affected MATS Continental

Division’s domestic aeromedical evacuation responsibilities. Contract carriers

were used to augment the Pacific Division’s airlift capability as were C–54s

drawn from MATS Atlantic and Continental Divisions and from troop carrier

units as well.

Aeromedical evacuation teams were provided from the 1453d MAES, which

was headquartered in Hawaii and had a detachment at Tokyo’s Haneda airport. A

composite organization, the 1453d was staffed with Air Force nurses and medical

technicians and Navy nurses and medical corpsmen. Just as aircraft resources

were augmented from other sources, the 1453d received reinforcements from the

Navy and MATS divisions and from elsewhere in the Air Force.

Evacuation teams and aeromedical evacuation flights were subjected to

changing evacuation requirements for most of the first year of the Korean War

because of the fluctuating casualty rates and changes in theater evacuation policy.

Policy changes could create instant backlogs, as when the FEC on December 3

halved the theater evacuation policy from 120 days to 60. An instant backlog of

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2,000 patients resulted. Variations could be large even when the evacuation policy remained basically constant. During October 1950, the Pacific Division evacuated 2,453 patients; in November the number was 1,907; but in December the

evacuees numbered 6,214, which proved to be the peak month during the war.

Evacuation requirements stabilized as the truce talks began and when greater

experience and coordination between FEC and the Pacific Division permitted better planning. Ultimately, MATS evacuated 60,965 patients from the entire Pacific

area from July 1950 through June 1953.58

Together with the workhorse C–54s, C–97s were used extensively for

aeromedical evacuation. The C–97’s cabin pressurization and greater speed provided a major advantage for seriously wounded patients. Contract carriers were

used selectively for airlifting patients. In mid-December 1950, a pressurized Pan

American Airways plane flew seventy-six chest-wound casualties from Tokyo to

Honolulu.59

Prior to the Korean conflict, MATS had not had a single focal point for

aeromedical evacuation, but this responsibility was soon vested in the command

surgeon. This organizational change, plus the importance that aeromedical evacuation acquired by virtue of its life-saving potential, helped ensure that its importance as part of the MATS mission would retain visibility.

C–97s were also used for domestic aeromedical evacuation, and the surge in

patients being moved among hospitals in the United States led to a reorganized and

expanded domestic system. As used in Pacific Division transpacific evacuation

flights, medically modified MC–54M aircraft were scheduled as much as possible.

The Continental Division had been using dedicated air transport squadrons distributed geographically around the country, and the larger wartime movements caused

it in June 1952 to create a new squadron, the 1731st Air Transport Squadron (Air

Evacuation) and base it at Scott AFB, Illinois. Domestic patient movements during

the Korean conflict totaled 215,402, and the peak month, as with the transpacific

aeromedical evacuations, was December 1950 when 10,153 patients were transported. These levels of activity were such that the Air Force procured its first

aeromedical evacuation aircraft specifically designed for and dedicated to this mission, the Convair C–131A Samaritan. Joining MATS initially in 1954, it could

carry twenty-seven litter and seven ambulatory patients, or thirty-seven ambulatory patients. Pressurized and designed with onboard facilities for medical care, it

was a major asset to the newly invigorated domestic system.60

Other byproducts of the Korean conflict that had an effect on aeromedical

evacuation included the 1952 establishment of the CRAF to provide a reserve of

long-range civil aircraft that could be activated incrementally and used to augment

the military’s airlift requirements in a crisis. The CRAF plan recommended that

litter-carrier fasteners be installed on all four-engine transports manufactured in

the future. This was a policy that the surgeon general had been seeking to implement. It represented a significant step toward the recognition of the value of the

Air Force’s aeromedical evacuation capability and served as an important basis

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for its potential future expansion.61 Less positive, however, were plans to reduce

the Air Force’s air transport capability in the wake of the Eisenhower administration’s emphasis on strategic deterrent and its budget-balancing program. The

transport service’s size and visibility made MATS a target for civilian airline

industry complaints that it provided unfair competition and should be reduced to

support the mission of the Strategic Air Command.62

The business orientation of the Eisenhower administration also resulted in the

imposition of a new accounting method, the Airlift Service Industrial Fund, for

budgeting the costs of airlift services. The other military services would budget

yearly for such services that would generate an accounting transfer of funds when

delivered. Because aeromedical evacuation was an Air Force mission, the cost of

this service was allocated to the Air Force.

By creating a single manager for airlift in December, President Eisenhower’s

Secretary of Defense consolidated control of all aircraft flying point-to-point

scheduled service under MATS. Intended like the adoption of industrial funding

to introduce greater efficiency and economy into the military air transportation

system, Secretary Wilson’s directive increased the number of transport aircraft

potentially available for aeromedical evacuation. It also stressed the peacetime

use of commercial airlift to enhance their wartime ability to support military

forces, an emphasis that provided another channel for seeking enhanced aeromedical evacuation capability. The assignment of aeromedical evacuation missions to

Air National Guard (ANG) units complemented these enhancement possibilities.

Conclusion

The Korean War served as a catalyst to clarify to the Army and Air Force the

value of aeromedical evacuation. Assigned the responsibility for developing

aeromedical evacuation systems for both services in the late 1940s, the Army had

neglected the task of forward or battlefield evacuation. This was a mission that the

AAF had rejected in 1942 when it was proposed by the wartime air surgeon,

General Grant, but it was a mission the USAF Air Rescue helicopters would perform with great effectiveness in the early phases of the Korean War. This demonstration of successful aeromedical evacuation led the Army to embrace the helicopter enthusiastically, particularly when its other tactical applications became

apparent. The initial Air Force rejection of dedicated helicopter rescue units soon

changed to proposals for providing a complete range of aeromedical evacuation

services from picking up battlefield casualties to delivering them at hospitals for

definitive care. Thus was the issue of the control of battlefield casualty pickup

injected into the ongoing Army–Air Force dispute over tactical air support of the

ground forces.

The Korean War marked the Army’s acceptance of aeromedical evacuation,

and the resolution of the frontline evacuation dispute helped lay the basis for the

distribution of responsibilities for aeromedical evacuation within a theater. The

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The Korean War and the Modern Aeromedical Evacuation System
role MATS played in emergency logistic support at the beginning of the conflict

and its continuing value in that role, including the return of casualties to the

CONUS, demonstrated the significance of air transportation for future conflicts.

A number of ripple effects redounded positively upon the role of aeromedical

evacuation among MATS’s responsibilities. The basic structure of the modern

aeromedical evacuation system that emerged in the wake of the Korean War and

the advances that would occur during the next dozen years would generate the

modernization of the transport fleet.

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Chapter 6

THE MODERN AEROMEDICAL EVACUATION

SYSTEM EMERGES FROM

THE WAR IN VIETNAM

The aeromedical evacuation system for the U.S. armed forces that emerged

from the Korean War experience was in great part due to the development of a new

technology, the helicopter. The apparent resolution of conflict between Army and

Air Force over its control and the Army’s final acceptance of aeromedical evacuation for its medical, logistic, and tactical value were engrafted onto the World War

II experience. The issue over the mission and control of rotary wing aircraft only

became resolved in 1966 during the Vietnam conflict, and ambiguities regarding the

Army’s and Air Force’s respective responsibilities for aeromedical evacuation as

delineated in the Medical Service in Joint Overseas Operations, the joint manual

issued in January 1956, would remain.1 A new recognition of the critical role of airlift to operational planning and combat support had emerged from the Korean War

and, with the new overseas commitment to NATO, the fact that airlift was a critical

resource requiring centralized management and modernization became apparent.

An emerging issue was how large should an active aeromedical evacuation

system be, or could it be maintained in peacetime, given the high cost of the medical personnel involved. Flight surgeons, flight nurses, and air evacuation technicians had been difficult to recruit in the required numbers in the post–World War

II era. Although SAM had successfully expanded the training of aeromedical

evacuation personnel for the Korean War, an exodus of personnel similar to what

followed World War II occurred again. Medical professionals were simply not

content to have their skills and special training either unused for long periods or

put to use in dispensaries or hospitals in routine military medicine. Yet it was clear

that another contingency similar to the one in Korea would require an expanded

aeromedical evacuation capability, and MATS had a continuing requirement to

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The Modern Aeromedical Evacuation System Emerges from Vietnam
operate the domestic aeromedical evacuation system that had expanded and been

rationalized during the war years. What size and capability might be required during time of war posed a difficult conundrum.

One solution to the problem of cost was to reduce the size of the active force

devoted to aeromedical evacuation in peacetime but to preserve its ability to

respond to crises by developing an aeromedical evacuation capability in the ANG

and the Air Force Reserve (AFRES). To this end, the mix of forces in the AFRES

and ANG was changed after the Korean War as the Air Force structure was

reduced and redirected. When mobilized in late 1955 and 1956 the ANG began to

activate aeromedical transport squadrons committed to MATS, and other measures were taken over the next few years to ensure such units were operationally

ready. Arrangements were made to attach AFRES flight nurses to ANG units for

training, and a special course for aeromedical evacuation technicians was established at SAM. Additional spaces were obtained for Guard personnel in specialized courses at SAM, the Armed Forces Special Weapons Medical Symposium,

and Army medical centers.2 In the 1950s the Continental Air Command eliminated six reserve fighter-bomber wings. Of the ten reserve troop carrier wings that

remained, each was required to provide a tactical hospital. Continental Air

Command also required them to create reserve aeromedical evacuation and casualty staging units. The hospitals were created in April 1957, and the aeromedical

units were created in April and May 1959.3

USAF headquarters also took another approach to cutting costs. Under budgetary pressures, Air Force Chief of Staff Gen. Thomas D. White, apparently

without consulting the Air Force surgeon general, went as far as seeking virtually

to eliminate the active force commitment to domestic air evacuation. The USAF

FY 1961 budget proposed cutting aircraft assigned to domestic air evacuation

from thirty-one to fifteen by September 1960 and eliminating the mission completely by 1963. Presumably, pressure from the Army and from within the DoD

caused White to quickly back away.4

Meanwhile, the Air Force continued its attempts to develop aeromedical

evacuation doctrine for theater operations. With the cession of frontline evacuation to Army aviation after the Korean War, the initial organizational actions of the

Air Force surgeon general to support frontline evacuation requirements were no

longer fully applicable. The aeromedical evacuation system proposed by Surgeon

General Harry Armstrong in 1951 essentially merely added a structure for frontline evacuation to the system previously developed ad hoc under the aegis of the

315th Air Division during the Korean War. Armstrong had proposed a hierarchy

of new aeromedical units for receiving, processing, and holding casualties, with

the assumption that Air Force helicopters and assault transports would be the primary vehicles used to perform frontline evacuation.

In the Eighteenth Air Force’s “Concept of Aeromedical Evacuation in

Overseas Combat Areas,” approved by USAF headquarters in March 1955, the

functions of forward medical air evacuation flights that Armstrong had proposed

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were narrowed. Originally described as operating in conjunction with Air Force

helicopter units and other units with assigned liaison or assault aircraft “to provide

treatment and movement for aeromedical evacuees from a forward battle area,”

including flight escort, their venue was now the drop or landing zone in which

Army troopers had been delivered by Air Force aircraft.5 The reception function

of these forward medical air evacuation flights was now allotted to casualty staging flights (CSFs), which were intended to be mobile and serve patients from any

source delivered to them.

In addition to receiving and processing patients for aeromedical evacuation

to the COMZ and possible further evacuation to the CONUS, directives required

that CSFs also provide holding facilities for in-transit patients. Coordinating

aeromedical evacuation requirements with theater airlift or MATS controllers

would be the responsibility of aeromedical evacuation control centers (AECCs).6

In effect, the Air Force’s concession of responsibility for frontline evacuation

to the Army had formally created a three-tier aeromedical evacuation system: a

frontline portion in which both the Army and Air Force had responsibilities, with the

Army having primary responsibility for picking up casualties in the combat zone; a

TAES operated by troop carrier or other theater airlift units to move patients from

the combat areas to the medical facilities in rear areas (normally, the COMZ); and a

strategic aeromedical evacuation system operated by MATS for intertheater patient

movement to the United States and distribution among domestic medical facilities.

Rooted in the Korean War experience, the aeromedical evacuation system

with which the U.S. armed forces would engage in hostilities in South Vietnam

approximated the three types of aeromedical evacuation envisioned by Colonel

Truby the chief of the Air Service medical division forty years earlier. Conditions

of conflict in Vietnam—the exigencies of fighting a guerrilla insurgency with no

clear front lines in a country with large stretches of sparsely populated jungle and

a limited road and rail network—would tend to shape the system in ways not necessarily congruent with agreed-upon doctrine. Additionally, the helicopter’s capability and the geography of Vietnam made it feasible to move casualties directly

to field hospitals. A more subtle factor that would affect the Army’s attitude

toward the traditional chain of evacuation was the performance of Air Force helicopters during Southern Pine, the 1951 joint Army–Air Force exercise. One major

result was the conclusion by the Army Medical Department that the Air Force’s

policy of bypassing some echelons on the traditional evacuation system, when

possible, was desirable. This marked a shift from the Army’s policy in Korea

when the Eighth Army surgeon had vetoed Air Force suggestions to this effect.7

Aeromedical Evacuation Developments

Between Korea and Vietnam

Perhaps the most notable event in the period between Korea and Vietnam was

the procurement of the first USAF aircraft developed specifically for aeromedical

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evacuation, the C–131A Samaritan.8 A pressurized aircraft, the Samaritan had two

engines and cruised normally at 235 mph. Air-conditioned in flight, it was cooled

by only a blower when on the ground, which proved inadequate for patient comfort. Passenger seats faced rearward and were capable of withstanding substantial

gravity forces. The cabin was designed to medical specifications and permitted

the installation of a variety of special medical equipment such as iron lungs, orthopedic beds, artificial kidneys, or incubators for transporting patients. The aircraft

could carry thirty-seven ambulatory patients or twenty-seven litter and four ambulatory patients and a medical crew of three. In accordance with the Geneva

Convention, the Samaritan had a large red cross on its vertical stabilizer, the first

such USAF aircraft to do so.9

Stimulated by the flow of Korean War casualties to the United States, the Air

Force had authorized Samaritan procurement in late 1951 to replace the aging

VC–47s in the domestic aeromedical evacuation system. By early 1955, MATS

squadrons assigned to the domestic system were fully equipped with twenty-six

C–131As and six MC–54Ms, but a combination of factors began to affect the system adversely. The lack of pressurization of the now-aging C–54s limited their

utility for flying patients over the Rocky Mountains, although having four engines

made them the most desirable aircraft for mountain flying. Additionally, the availability of C–54s began to decline because they required extensive maintenance to

keep them operational while the C–131As were receiving programmed major

maintenance, and two were transferred to Europe. The assignment of the pressurized, four-engine C–118 Liftmasters to the system helped cover these losses, and

the procurement of nine C–131Es enabled MATS to retire the MC–54Ms, which

were gone from the domestic system by 1958.10

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The Douglas C–118 Liftmaster outfitted for aeromedical evacuation duties.
This now-modern fleet of pressurized, propeller-driven aircraft supported a

trunk-and-feeder system connecting the major aerial ports of entry on the East and

West Coasts through a series of intermediate stops and an occasional flag stop.

Trunk flights were flown by dedicated aircraft on a scheduled basis between Air

Force bases located near major hospitals; feeder flights to these bases were made

from scattered airfields to bring in patients who needed more definitive care.

Centralized control of the five squadrons of the MATS Continental Division

assigned to the domestic system was exercised by the 1st Aeromedical Transport

Group headquartered at Brooks AFB, San Antonio, Texas. In 1953, the

Continental Division had created its predecessor, the 1706th Air Transport Group

(Air Evacuation), to decentralize authority and improve supervision. This action

was also intended to facilitate the group’s conversion to the C–131A. Patient

movement control centers at squadron locations coordinated patient movement on

the scheduled trunk-line flights, and the 1st Aeromedical Transport Group controlled domestic system operations through an aircraft flight-following and movement control center at Brooks. Trunk-line itineraries varied over the late 1950s as

MATS modernized its domestic aeromedical evacuation aircraft fleet. Travis

AFB, California, and McGuire AFB, New Jersey, were the western and eastern

terminuses; intermediate stops included Brooks AFB; Brookley AFB, Mobile,

Alabama; Andrews AFB, Maryland; Scott AFB, Illinois; and Lowry AFB,

Denver, Colorado. Charleston, South Carolina, served as a flag trunk stop.11

The 1st Aeromedical Transport Group issued new schedules and developed

new route structures that reduced by 37 percent the time spent in flight. These also

ensured that, during 80 percent of each day, an aeromedical evacuation aircraft

was flying within the area served by the using hospital and a flight could easily be

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The Convair C–131 Samaritan.
diverted to a nearby base to meet an emergency evacuation of a patient. Patient

handling for those moving through the system was improved and brought under

direct MATS control in 1957 by creating CSFs at McGuire, Travis, and Scott

AFBs. The CSFs undertook tasks previously performed by local hospitals that

tended to strain their capability to meet their base responsibilities. For example,

6,300 patients were processed by the Aeromedical Evacuation Section of the Scott

AFB hospital during 1954, which led ultimately to unrealized plans to curtail

dependents’ medical care.12 To preclude such situations, the 1st CSF was activated at Scott on January 18, 1958, and the 2d CSF, which would be the focal point

for most of the returning casualties during the Vietnam War, was activated at

Travis AFB on the same date. The mission of the MATS CSFs was to receive and

process patients for transport, provide nursing service for patients in transit, transport them to and from the aircraft, and load and unload them.13

The stimulus provided by the Korean War for modernizing the domestic

aeromedical evacuation system focused attention on what the USAF and MATS

should plan for regarding airlift and aeromedical evacuation requirements. No Air

Force or DoD directive mentioned a wartime mission for MATS, but creation of

the Single Manager Operating Agency for Airlift (an enlarged MATS) remedied

this deficiency. DoD Directive 5160.2 designated the Secretary of the Air Force

as the agency’s single manager and the MATS commander as the agency’s executive director. It also directed the Secretary of Defense to “organize, equip and

attach air transport units necessary to meet military requirements as determined

by the Joint Chiefs of Staff.”14 The directive applied to all aircraft operating pointto-point on a scheduled basis or “aircraft whose operations are susceptible to such

scheduling.” In accordance with its terms, all but twenty of the Navy’s fourengine Fleet Logistic Air Wing’s transports and all of TAC’s heavy, troop carrier

aircraft (the C–124 Globemaster II) were transferred to MATS.15 The loss of a

major portion of TAC’s troop carrier fleet made maintaining a separate troop carrier organization unjustifiable, and Headquarters Eightenth Air Force was disestablished. The concepts it developed for theater aeromedical evacuation systems

were embodied in Headquarters USAF, TAC, and theater manuals and regulations

and generally paralleled those specified by MATS.

TAC’s mission was now to train tactical units for assignment to overseas

commands or joint task forces (JTFs) constituted to provide quick response with

a balanced and tailored U.S. force for worldwide contingencies. An example of

this would be the post-1961 United States Strike Command. Limited war such as

the Korean conflict just past, a general war like World War II fought with conventional weapons, or a nuclear war with the Soviet Union—all posed potentially different requirements for aeromedical evacuation, making it difficult to develop programs to procure and train personnel for such a system. The structure of the

aeromedical evacuation system and procedures for operating it were, however,

available in the appropriate theater regulations and manuals. For the Pacific, these

were issued by the Hawaiian headquarters of Pacific Air Forces (PACAF), which

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A History of Aeromedical Evacuation in the U.S. Air Force
on July 1, 1957, had replaced FEAF after the U.S. armed forces in the Pacific

moved from Japan to Hawaii at the end of the fighting in Korea. Pacific

Command (PACOM) replaced FEAF’s parent, FEC, at the same time.16

While the domestic aeromedical evacuation system was being modernized,

and the theater systems and MATS were adjusting to the new peacetime requirements for moving U.S. patients worldwide, the system was exercised in several

contingencies that did not involve U.S. combat casualties. One of the first exercises was the aeromedical evacuation of wounded and sick French legionnaires

from Indochina in June 1954. This occurred in the wake of the French surrender

to communist Vietminh forces at Dien Bien Phu in May 1954 and the French

agreement to relinquish control of its former colonies. Four-engine C–124 troop

carrier aircraft of the 315th Air Division airlifted the French troops from the Tan

Son Nhut airfield at Saigon to Tachikawa AB in Japan in Operation Wounded

Warrior. From Japan, MATS flew the troops on C–97s across the Pacific to the

United States and thence by C–118s to France and Algeria.17

Other contingencies during the interval between Korea and Vietnam in which

MATS aeromedical evacuation capabilities were available to support U.S. or

friendly forces included the 1956 airlift in support the rebels during the Hungarian

Revolution; the 1958 Operation Blue Bat, the joint deployment of an Army task

force to Lebanon from Germany; and the 1960 airlift, Operation New Tape, to the

former Belgian Congo in support of the United Nations. In contrast to Wounded

Warrior, these three operations were not aeromedical evacuation missions.

Foreshadowing a new Cold War interest in the Middle East, Operation Blue Bat

was conducted at the request of the Lebanese president who was concerned about

preventing the possible overthrow of his government after the successful 1954

coup in Iraq against the British-supported Hashemite king.18 Neither Blue Bat nor

New Tape received the benefit of JCS medical planning, according to the senior

Air Force medical officer in Europe who was responsible for the medical support

of these operations. This, he asserted, was typical of the lack of attention paid to

medical issues by the JCS during this period.19

Changes in the Status of Airlift and MATS Capability

The creation of a single manager for airlift in 1956 had been occasioned by

the Eisenhower administration’s interest in greater efficiency through centralized

control of what would soon be called strategic airlift. After 1956, reality showed

that control of airlift in the armed forces was not as centralized as the DoD’s directive suggested, but it represented a definite, albeit imperfect, step toward that

end.20 The focus on airlift represented by the creation of a single manager also

reflected continuing congressional interest. Stimulated in large part by commercial air carriers, which aroused their congressional delegations with the charge

that MATS transport of passengers and cargo represented unfair government competition, several congressional committees and subcommittees conducted a series

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of hearings in which a number of issues were aired and recommendations made

regarding future airlift policy.21

Aeromedical evacuation seems to have hardly been discussed in any of these

hearings. In perhaps the most important one, a special subcommittee of the House

Armed Services Committee on military airlift and chaired by the powerful South

Carolinian, Mendel Rivers, aeromedical evacuation was mentioned only in passing. In a background briefing to the members of the subcommittee, Col. Walter

Cook, the MATS deputy assistant chief of staff, when describing aeromedical evacuation, revealed Air Force plans to phase out the domestic system along with other

support operations “in order to maintain combat strength at the required level.”22

The chairman’s comments during the hearings clearly indicate he was not

sympathetic to the Air Force’s priorities. He expressed concern at what he perceived as the secondary status accorded MATS by the Air Force leadership and

the responsibility of the Air Force to support the Army as prescribed by previous

agreements and directives. Rivers was obviously sympathetic to the need for more

airlift capability; he was quoted in the Army Navy Air Force Journal’s coverage

of his subcommittee hearings as having said that the airlift shortages revealed in

the hearings were frightening. In an exchange with Air Force Chief of Staff

General White, Rivers goaded him a bit with the idea that MATS be made a specified command as one way “to put the responsibility on somebody and stop some

of this lip service [to Air Force support of MATS].”23

The most positive development from these hearings was Congress’s acceptance that turbojet aircraft were needed to modernize MATS. MATS argued that

an uncompromised military cargo transport powered by jet engines and designed

specifically for the purpose had to be developed, and that, because the need was

so urgent, an off-the-shelf aircraft was mandatory until the required aircraft was

available.24 Both would be fitted to carry litter and ambulatory patients for

MATS’s strategic aeromedical evacuation mission.

Similar attention was paid during these hearings to improving tactical airlift.

A start was made by DoD, but any substantial action would be deferred until a

new administration with a different vision of how best to preserve U.S. national

security took charge. This congressional attention to the future of airlift transcended the change from the Eisenhower to the Kennedy administration. More to

the point, the change of administration brought a change in the strategic concept

around which the U.S. armed forces were organized. The Eisenhower administration emphasized the U.S. nuclear strike force embodied chiefly in the Air Force’s

Strategic Air Command (SAC), whereas Kennedy’s emphasized a range of conventional and nuclear forces with which to respond to a given situation at an

appropriate level of intensity. The concept of flexible response was consonant

with the Army’s outlook that limited wars, like the Korean conflict, were probable and required a conventional response, rather than what they asserted was the

potentially suicidal and increasingly incredible threat to meet aggression with a

nuclear attack on the aggressor.

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Flexible response required adequate conventional forces and the airlift to

move them quickly to where they were needed, in contrast to reserving airlift

strictly to support SAC in its conduct of a nuclear exchange. That meant modernizing MATS with jet transports; reevaluating the capabilities of the CRAF, and

examining how it should be utilized in future contingencies; and in accordance

with Air Force policy already being implemented, moving surplus transport aircraft into the ANG and the AFRES to increase their airlift capability.25 Concerns

about domestic air evacuation disappeared; instead, expansion and modernization

of both tactical and strategic airlift were to be undertaken. By implication, both

tactical and strategic aeromedical evacuation were to have heightened roles. In his

first inaugural address, President Kennedy stated plainly that he had directed

prompt attention to increase airlift capacity because

obtaining additional air transport mobility—and obtaining it

now—will better assure the ability of our conventional forces to

respond, with discrimination and speed, to any problem at any

spot on the globe at any moment’s notice.26

Immediately after President Kennedy’s address, attention to increase airlift

occurred: the initial buy of fifty long-range C–130E Hercules in the previous

Eisenhower defense budget, one of the tangible results of the recommendations of

the Rivers subcommittee, was increased to ninety-nine; and seventeen KC–135

Stratotanker jet tanker aircraft on the production lines were ordered reconfigured

as transports. An additional thirteen C–135 Stratolifters were also ordered. These

new jet transports were to become available at the rate of two per month beginning in June 1961. With an audit trail extending back into the previous administration, the uncompromised jet cargo aircraft went into development in 1961 with

the selection of the Lockheed C–141 Starlifter.27

On the eve of the U.S. intervention in Vietnam, the USAF had received its

first jet transport, the C–135, for intertheater evacuation. Within a few years it

would receive C–141s. Additionally, it had a growing theater force of assault

transports and doctrine drawn from the Korean War to support tactical aeromedical evacuation. Complementing the Air Force’s aeromedical evacuation capabilities were Army medevac28 helicopters and smaller fixed-wing aircraft that could,

as was demonstrated in World War II and the Korean conflict, evacuate small

numbers of casualties in emergencies.29 However, the line separating Air Force

tactical aeromedical evacuation from Army frontline evacuation remained somewhat ambiguous.

Factors Affecting Aeromedical Evacuation in Vietnam:

Roles and Missions

A memorandum of November 26, 1957, from the desk of Secretary of

Defense Wilson gave the Army the right to operate aircraft for several traditional

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Army functions within an enlarged combat zone that was 100 miles forward and

to the rear of the line of contact between U.S. and enemy forces. These functions

included command, liaison, communications, observation, reconnaissance, and

fire adjustment, but Wilson also affirmed the more contentious roles for Army aviation secured during the 1950s that the Air Force believed encroached on its troop

carrier mission: aeromedical evacuation and the airlift of Army personnel and

material. Wilson specified Air Force responsibilities to be strategic and tactical

airlift (the airlift of Army personnel and materiel into and out of the Army combat zone, including support of airborne operations) and

aeromedical evacuation from Air Force operating locations

within the combat zone through Air Force casualty staging units

to hospital facilities outside the combat zone, and aeromedical

evacuation from an airhead or an airborne objective area where

airborne operation includes air landed logistic support by Air

Force.30

The Air Force was also responsible for tactical reconnaissance, interdiction of the

battlefield, and close combat air support.

That the Army was not content with this division of labor and responsibilities

quickly became obvious as it continued to press for expanding the role of Army

aviation in ground combat. When the Kennedy administration came to power in

1961, the Army’s leadership found the environment conducive to advance its concepts. The outcome was the June 1965 decision by Secretary of Defense Robert

McNamara to authorize the first air mobile division built around the intensive

application of helicopters to ground combat. The Air Force considered that the

Army’s deployment of armed helicopters, battlefield surveillance capabilities, and

very-heavy-lift helicopters constituted a clear violation of the roles and missions

that had been assigned it as well as a costly duplication of its capabilities. The official Air Force concept for employing tactical airlift included air logistic support

for combat forces through establishing and maintaining “an air line of communications” for personnel, supplies, and equipment to Army supply points and to

combat units, “regardless of their size or location.” Air Force tactical airlift was

also to move units within the combat zone, conduct aeromedical evacuation operations, provide emergency supply and resupply, and transport the special forces.31

By contrast, Army Chief of Staff Gen. Harold K. Johnson in testimony before a

special subcommittee on military airlift of the House Armed Services in October

1965 cited “the retail line of communications operated by the Army [emphasis

added]”; Army dependence on the Air Force to support Army requirements “as far

as they can operate their aircraft efficiently...consistent with our tactical mission”;

and Army fixed-wing twin-engine transports, the C–7 Caribou and C–8 Buffalo,

as the logistic link between “the long-range bulk carriers [Air Force C–130s], and

Army helicopters in the forward areas.”32 Air Force concerns about Army

encroachment on Air Force missions would follow this first airmobile division—

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A History of Aeromedical Evacuation in the U.S. Air Force
the 1st Cavalry Division (Airmobile)—into Vietnam, where it deployed soon after

its activation in 1965. When the division arrived in-country, it brought with it its

own, organic helicopter medevac capability.33

The Context of Aeromedical Evacuation in Vietnam,

1961–1968

U.S. involvement in Vietnam progressed through several phases. In the first,

the United States supported the French attempt to suppress the Vietminh insurgency in the early 1950s through a military advisory assistance group (MAAG).

The MAAG administered military assistance programs that supplied aircraft,

munitions, and other direct services, including logistic and maintenance support

supplied by the USAF for aircraft sent to Indochina. In the second phase, the

United States provided support to the noncommunist South Vietnamese government that emerged after the partition of Vietnam in 1954. The vehicle was a similar assistance program administered by a MAAG and included U.S. Army, Air

Force, and, after May 1961, special forces advisors. In November 1962 the U.S.

Military Assistance Command, Vietnam (MACV), a subordinate unified command

under the commander in chief, Pacific Command (CINCPAC), was established to

manage the deployment of U.S. advisors and materiel. When the United States

decided in 1965 to intervene with U.S. ground troops, MACV directed U.S. combat operations and the buildup of U.S. forces. This approach lasted through 1968

when President Lyndon Johnson made the decision to reduce the U.S. role and turn

over the war to the South Vietnamese, the so-called Vietnamization program.

MACV then oversaw the drawdown of U.S. forces from 1969 through their complete withdrawal in the early 1970s until MACV’s deactivation in March 1973.36

This gradual path that led to the introduction of U.S. forces into combat in

Vietnam conditioned the development of the aeromedical evacuation system.

Initially there was a lack of appreciation for the number of troops that would eventually be deployed (they numbered some half a million at the height of hostilities

in 1968). This created an ad hoc approach to the development of a system for casualty evacuation, which was further encouraged by ambiguities in the theater command structure for airlift and associated aeromedical evacuation responsibilities.37

The Origins of the Aeromedical Evacuation System,

1961–1965

After the Kennedy administration’s decision to increase aid to the Diem government in 1961, a buildup of medical facilities began to accommodate the 8,000

U.S. military personnel planned to be dispatched as advisors to bolster the South

Vietnamese government forces. The first helicopter units that deployed to

Vietnam were not dedicated medevac units; those began arriving in December

1961 with H–21 light helicopters. In late April 1962, the first dedicated medevac

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The Modern Aeromedical Evacuation System Emerges from Vietnam
unit, the 57th Medical Detachment (Helicopter Ambulance), arrived. It was

equipped with UH–1As, the first Hueys to be deployed to Vietnam.38

Following the practice begun during the Korean War, the 57th was assigned to

the Army Medical Department. It was stationed initially at Nha Trang, a coastal

town 265 miles northeast of Saigon with the 100-bed 8th Field Hospital and four

attached medical detachments sent with the 8th to provide specialty care. All these

units had been alerted for dispatch in the preceding February to ensure that the

incoming U.S. advisors would have a full range of medical services available. Their

assignment to Nha Trang prevented further overloading an already overcrowded

Saigon, which appears to have been the principal reason for the decision to send the

detachment north. The Vietnamese air force was responsible for meeting the evacuation needs of the Vietnamese army, but it had no dedicated medevac units. It used

H–34s for evacuations, but the helicopters performed erratically, if at all.39

Reminiscent of earlier controversies, the issue of command and control of

aeromedical evacuation aircraft arose several months after the 57th’s arrival and

was precipitated by the relative inaction of the unit. Located several hundred

miles from the delta and other areas where most of the fighting was occurring, the

57th’s helicopters had a limited radius of action of some 90 miles. By June, they

had evacuated only twelve U.S. and fourteen Vietnamese army40 personnel, and

the 57th’s commander assigned two Hueys to Qui Nhon, 100 miles farther north

on the coast in an attempt to extend medevac coverage. He also sought with only

partial success to have JP–4 fuel for the helicopters stored inland in several critical locations, and he tried several times without success to get permission to move

the 57th to Saigon or the delta where it would be closer to the fighting. Although

he was later a strong supporter of the 57th’s aeromedical evacuation mission, in

September Gen. Joseph Stilwell, commander of the Army Support Group,

Vietnam, considered transferring the 57th from control of the Army Medical

Department to the Army Transportation Corps, which controlled all U.S. Army

helicopters in Vietnam at that time. According to the historian of the medical

department in Vietnam, Stilwell observed the 57th’s relative lack of activity and

thought its restriction to medevac was a waste of resources and that its medevac

helicopters should be used for other logistic missions.41 Stilwell dropped his idea

only after representations by the 57th commander and the Support Command surgeon, who also commanded the 8th Field Hospital.42

Stilwell was not alone in focusing initially on how to meet operational

requirements in light of the nature of Vietnamese geography, the guerrillas’ tactics, and the increased but still limited resources available. As the historians of

helicopter aeromedical evacuation in Vietnam note, all commanders of Army aviation units in South Vietnam met as early as July 1962 to discuss the possibility

of employing Army aviation extensively to support South Vietnamese counterinsurgency efforts. They were briefed that greater U.S. military involvement would

require that Army aviation assume tasks ordinarily assigned to armor, ground

transport, and infantry.43

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All Army aviation units were suffering from inadequate logistic support, and

not until November 1962 did the still unique medevac Hueys have an established

logistic channel to provide spare parts. Helicopter resources were scarce, and

some Army aviators argued against having dedicated helicopters for aeromedical

evacuation. They even suggested that the red crosses displayed on them be

removed and that the helicopters be assigned general support tasks when they

were not engaged in medevac missions. In the same vein, the Army Support

Command suggested that the identifying red crosses be displayed on removable

panels. The senior MAAG advisor in Qui Nhon went so far as to try several times

to commandeer a standby medevac helicopter.44 Not until early 1963, after the

Vietnamese army mounted a heliborne assault in the delta that resulted in heavy

casualties, including three dead U.S. advisors, did moving the helicopter ambulances closer to the fighting receive serious consideration. The 57th was ordered

to Tan Son Nhut airfield at Saigon on January 16. Reflecting both the more serious consideration being given to aeromedical evacuation by MACV and the continuing influx of U.S. equipment, in March General Stilwell gave the 57th the first

new-model Hueys, UH–1Bs, to arrive in Vietnam.45 Over the next two years, the

57th placed detachments at Pleiku in the central highlands and Qui Nhon, again

to provide medevac support within the II Corps zone, whereas the remaining aircraft of the 57th at Saigon provided similar support to the III and IV Corps zones.

In the northernmost I Corps zone, where U.S. Marines fulfilled the advisory role,

Marine Corps H–34 helicopters provided both aeromedical evacuation and combat support. By June 1963, some type of capability for forward area helicopter

aeromedical evacuation was available to all of South Vietnam, although the dedicated coverage provided was thin.

The initial Air Force role in aeromedical evacuation began with the dispatch

of twin-engine C–123 Provider assault transports to Vietnam in January 1962 to

give tactical and logistic support to Vietnamese and U.S. forces in the field.46 In

many respects, C–123s were ideal for this role because they had been designed to

operate from short, rough, or unprepared landing strips in support of airborne

operations. The Air Force also envisioned C–123s as evacuating casualties on retrograde missions from forward areas, particularly from airborne assault areas in

emergencies. Capable of carrying either litter or ambulatory patients, the C–123,

like its Korean counterpart, the C–119, was not an ideal vehicle for moving the

sick or wounded. The noise level in the cargo compartment, which had no soundproofing, was very high, and because the aircraft was not pressurized, it could not

be air-conditioned for in-flight passenger or patient comfort. Vibration from the

engines and a tendency to yaw rhythmically during straight and level flight added

to the discomfort of those riding in the cabin.47

Whatever its deficiencies as a vehicle for aeromedical evacuation, the aircraft

was well-suited to support forces in outlying areas, especially the special forces

camps in Vietnam’s remote interior. Like the C–119 during the Korean War,

C–123s were used to evacuate casualties and patients when a more suitable aircraft

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The Modern Aeromedical Evacuation System Emerges from Vietnam
was unavailable. During the next several years, C–123s brought in the sick and

wounded from outlying locations to Tan Son Nhut, and a single C–123 was kept

on a twenty-four-hour alert at the airfield for a possible emergency aeromedical

evacuation request. An AECC was also established at Tan Son Nhut and manned

by two medical technicians who received evacuation requests and coordinated

patient movement between Tan Son Nhut and the 8th Field Hospital at Nha Trang,

which until April 1965 was the only U.S. Army field hospital in Vietnam.48

In October 1963, the Navy opened a 100-bed station hospital in downtown

Saigon to provide, for the first time, full inpatient and outpatient capability to support U.S. forces serving with South Vietnam’s III and IV Corps. Casualties from

these areas were initially transported by 57th helicopters to Tan Son Nhut and then

moved to the hospital by ground ambulance. Because the distance and the traffic

en route presented problems, an abandoned soccer field fifteen minutes away

from the hospital was converted into a helicopter landing pad, materially shortening the time between the pickup of a casualty in the field and the initiation of treatment at the hospital.49

The Air Force TAES continued to develop from these beginnings. C–123s

began scheduled evacuation flights weekly between Tan Son Nhut and Nha Trang,

taking patients to the 8th Field Hospital and bringing back patients and personnel

returning to duty to Saigon. Personnel from the AECC frequently served as

inflight medical crew during these flights. Major hospital cases were evacuated by

air from Vietnam to Clark AB in the Philippines because it had better medical

facilities; others were evacuated in accordance with the fifteen-day evacuation

policy adopted for Vietnam. Airlift squadrons equipped with four-engine turboprop C–130s based at Tachikawa AB, Japan, and Naha AB, Okinawa, moved

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A History of Aeromedical Evacuation in the U.S. Air Force

UH–1 Huey evacuating casualties in Vietnam.
patients regularly on backhaul missions from Tan Son Nhut to Clark. There, they

received further treatment at the hospital or were stabilized for MATS evacuation

to the United States. The theater evacuation policy was sixty days.

In May 1962, C–130s were put on a specific weekly aeromedical evacuation

schedule timed to meet the returning C–123s from Nha Trang, and connecting

Clark AB, Tan Son Nhut airfield, and Don Muang airport in Bangkok, where

another AECC was established. At least initially, the C–130s were A models

which, like their smaller transport brother, the C–123, had little or no soundproofing. Noise levels in the cabin might be uncomfortable for patients, but the

aircraft was fast and very stable in flight and the cabin was pressurized, which

reduced patient stress from flying at the high altitudes where the turboprops were

most efficient, and it provided climate control in the passenger compartment.50

Medical crew members from the 9th Aeromedical Evacuation Squadron (AMES)

at Tachikawa AB accompanied these C–130 flights, and in 1963 detachments of

the 9th AMES were established at the three terminal points. The system was

unstressed enough at this point in the deepening U.S. involvement to handle an

occasional emergency evacuation flight for a single patient on a diverted aircraft

with an informally augmented medical flight crew.51

Roughly 200 patients each month were moved to or from Southeast Asia during 1963–1964, and of these, fewer than 40 percent were battle casualties. The

system was clearly adequate to fulfill the then-current evacuation requirements.

Aeromedical evacuation in Vietnam up to 1964 had little resemblance to the evacuation systems the Air Force had built for the joint exercises conducted with the

Army after the Korean War52; this would remain largely true through the years of

direct intervention and troop buildup and withdrawal.

The same could easily be said for much of this period with regard to the airlift system in Vietnam upon which aeromedical evacuation largely depended.

Unlike the Korean conflict when the 315th Air Division had functioned as the

FEC’s single manager for airlift and been the major player in helping fashion and

then direct the theater aeromedical evacuation system, the command structure for

airlift and aeromedical evacuation in 1965 was more complex. The 315th Air

Division, still located at Tachikawa AB in Japan, now reported directly to PACAF

headquartered at Hickam AFB, Hawaii, which was the Air Force component of

the newly established (1957) unified theater command headquartered on Oahu.

Intratheater airlift was the 315th’s responsibility, and its 9th AMES, also headquartered at Tachikawa, provided the medical flight crews for required aeromedical evacuation. However, MACV, the Army-dominated subordinate unified command headquartered in Saigon in 1965, had, from its inception in March 1962, a

doctrinal bias toward decentralized control of a supporting airlift system.53 This

had the same roots as the Army’s aggressive promotion of Army aviation, that is,

if under Army command and control, it would be more responsive to the requirements of ground combat.54 This contrasted sharply with the Air Force’s belief in

the efficiency of centralized control of theater airlift, which the Korean conflict

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The Modern Aeromedical Evacuation System Emerges from Vietnam
had demonstrated to its satisfaction and which were embodied in its command

directives. Such centralized control also provided the most effective means to

coordinate aeromedical evacuation requests.55

The result of these differences produced a hybrid, the Southeast Asia Airlift

System for Vietnam. Established in late 1962, it was controlled by the newly created 315th Troop Carrier Group (Assault) at Tan Son Nhut AB. Although the

315th Group was formally assigned to the 315th Air Division in Japan, operational command of the unit was vested in the MACV commander who exercised

command though his Air Force component, and airlift capability was allocated by

a board established within MACV J–4 (Logistics). The degree of airlift centralization was not complete because the Army’s C–7 aircraft were largely excluded

from the system; they provided direct support to Army senior advisors in the field

and to MACV itself, much to the Air Force’s dismay. By 1963, a section of the

315th’s Operation Section had emerged as the airlift control center (ALCC) to

provide scheduling, flight following, and operational planning in response to airlift allocations from MACV.56

As U.S. involvement deepened in Vietnam, the Army imprint on MACV was

perhaps best exemplified when the Army brigadier general heading MACV J–1

(Personnel) proposed in 1964 that MACV be made an Army specified command

rather than continue as a subordinate joint command of PACOM. Denied this,

MACV was still reorganized by Secretary of Defense McNamara along lines suggested by the Army: Army Gen. William C. Westmoreland was placed in the new

position of deputy commander, MACV; the Air Force Deputy J–3 was replaced by

an Army officer because, according to the J–3, Maj. Gen. Richard Stilwell (son of

General Joseph Stilwell), he was unable to “look at J–3 matters except through

USAF-tinted glasses” and he knew nothing of ground operations; and the MACV

chief of staff position was filled by General Stilwell when the incumbent Marine

Corps brigadier vacated it, although Adm. Harry D. Felt, the CINCPAC, had

favored making the MACV chief of staff a senior Air Force officer to obtain an Air

Force perspective within the mainstream MACV operation.57 The Air Force also

lost the J–2 position to a Marine Corps brigadier general, and, when the MAAG

was closed out in May 1964, foreshadowing the change of mission that MACV

would undertake within a year, MACV requested 310 additional staff positions,

283 for the Army; 24 for the Navy/Marine Corps; and 3 for the Air Force.58

The Airlift System and Aeromedical Evacuation

During the Combat Years

A tactical airlift system that approximated Air Force doctrine and the centralization embodied in the 315th Air Division during the Korean War was finally achieved in 1966 and was essentially maintained during the following years of

U.S. combat growth and operations. The Southeast Asia Airlift System directed by

the 315th Air Commando Wing59 was replaced by the Common Service Airlift

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A History of Aeromedical Evacuation in the U.S. Air Force
System in October 1966 with the creation of the 834th Air Division. The new air

division absorbed the ALCC and assumed command of the 315th Wing and the

8th Aerial Port Group, which provided the specialized cargo reception and handling capability to the airlift system. The 834th also was given operational control

over C–130s based outside Vietnam when detachments of these aircraft were temporarily assigned on a rotating basis to several bases in South Vietnam.60

The numbers of C–130s and base areas from which they operated had

increased substantially by 1966. By the fall and winter of 1965–1966, twelve

C–130 squadrons were based in the western Pacific to provide logistic support to

operations in Vietnam. Besides the Japan and Okinawa C–130A squadrons, E and

B models were now based at Clark, Mactan in the Philippines, and Ching Chuan

Kang on Taiwan. C–130s were used until 1967 for scheduled evacuation flights

from Vietnam to Clark AB, when they were replaced by PACOM C–118s brought

from Japan and dedicated to aeromedical evacuation, a task that was extended to

include moving patients within the combat zone and Thailand.61 On January 1,

1967, the 834th took command of the 483d Wing, an organization formed to integrate into the Air Force the Army fixed-wing C–7s that were transferred pursuant

to the July 1966 agreement between the Army and Air Force chiefs of staff.62

Management of the new centralized system also improved. Earlier in March

1966 a new MACV joint movements transportation board with representatives

from MACV’s staff agencies and the component commands had begun to meet

and make monthly allocations of the combined sea and air transportation capability that was projected to be available to the command as a whole. A MACV traffic management agency also became fully operational in March to provide dayto-day management of cargo and personnel movements. These new transportation

and traffic management entities undertook the managerial role that the MACV

logistics section had previously attempted.63 The new system represented a considerable step toward centralized control of the airlift supporting MACV and the

U.S. combat effort in Vietnam. The greater control over the available airlift

resources also made it possible to realize greater efficiency in coordinating and

scheduling the work of the AECC with the ALCC at Tan Son Nhut. Reflective of

the still somewhat confusing organizational relationships, the AECC was operated by the 903d AMES, a former detachment of the 315th Air Division’s 9th

AMES at Tachikawa that had been established in July 1966. The 9th had itself

been elevated organizationally to an aeromedical evacuation group, and both the

new group and its subordinate organizations—the 903d AMES, the 901st AMES

at Clark, and the 902d at Tachikawa—remained under the 315th Air Division.64

The Mature Aeromedical Evacuation System, 1966–1968

The evolving relationship between MACV and the Air Force in operational

matters affected airlift and the TAES dependent upon it. The in-country and the

supporting PACOM airlift and aeromedical evacuation systems that had emerged

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The Modern Aeromedical Evacuation System Emerges from Vietnam
by 1966 both worked, and with some subsequent fine-tuning, worked well, but

occasional glitches did occur.65 Both systems succeeded due to the capability of

the responsible service members to provide ad hoc solutions to problems, sometimes contrary to doctrine, as had been discovered in the United States’ previous

two wars. Still, the institutional conflicts and different perspectives of the Army

and the Air Force conditioned the actual systems that emerged and helped shape

future organizations with the same missions.

In an inspection of the aeromedical evacuation system supporting MACV in

early 1966, the USAF Inspector General (IG) reported that it was excellent from

the medical standpoint, and it continued so during the rest of the conflict.66 The

number of hospitals grew rapidly after U.S. combat forces entered the country in

1965. At its peak, the Army had deployed seven surgical hospitals; eleven evacuation hospitals, including the 312th Evacuation Hospital, an Army Reserve unit;

four field hospitals; and one convalescent center to South Vietnam. In all they providing 5,283 beds. The Air Force and Navy operated hospitals at Cam Ranh Bay

and Danang, respectively, and Korean and Australian hospitals were also in-country.67 All major medical installations except the 3d Field Hospital at Saigon were

located at airfields from which C–130s could operate.

In addition to Air Force airlift, both dedicated and opportune that provided

aeromedical evacuation capability to support this hospital structure, twelve medevac helicopter units were in-country by the end of 1968, as were air ambulance

units integral to Army operational combat formations.68 The former MACV command surgeon, General Neel, much later described the aeromedical evacuation

system in-country broadly as a grid with Army helicopters moving casualties

across the narrow waist of the country from combat areas eastward to U.S. and

allied hospitals located along the coast, and Air Force aircraft operating north and

south between Saigon and Danang, transferring patients among in-country hospitals and evacuating those from South Vietnam whose recovery time would exceed

the MACV evacuation policy, now at thirty days because of the increased number

of hospital beds. He also noted the flexibility that each service exhibited, with the

Air Force removing casualties from frontline areas when Army casualties overloaded the Army medevac helicopters, and the Army sometimes moving patients

by helicopter from hospital to hospital.69

A notable example was the battle of Dak To, which began on November 1,

1967, when the large number of casualties sustained by the 173d Airborne

Brigade during a several-week-long battle threatened at times to overwhelm both

the brigade’s clearing and collecting unit and the medevac helicopters’ capability

to move casualties to the 71st Evacuation Hospital at Pleiku. Because so many

casualties began to back up while awaiting surgery and intensive care at the 71st,

Air Force C–130 missions backhauled the less seriously wounded to two evacuation hospitals at Qui Nhon. Later in the month, the 903d AMES deployed a mobile

CSF to provide much-needed support to the evacuation operation, which was still

hectic. An Air Force observer of the evacuation process wrote shortly afterward

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A History of Aeromedical Evacuation in the U.S. Air Force
that the Air Force CSF was doing an outstanding job of receiving litter patients

and caring for them in ten to fifteen minutes after their removal from the medevac helicopters and providing emergency life-saving care.

The C and C [clearing and collecting] physician and technicians

are only able to spend the time required with each patient to

assure a clear airway and to stop bleeding. All other life-saving

procedures are accomplished by the CSF, i.e., start fluids, IV

[intravenous injections] and whole blood, resuscitate and aspirate, rebandage and administer drugs. Many patients required

the full time attention of one nurse and two medical technicians.70

The observer further noted that a 55th Medical Group regulator was on duty in the

Air Force CSF and that frequent C–130 support missions into Dak To provided

the means to support the aeromedical evacuation requirements.71

General Neel’s description was undoubtedly overbroad, but it contained a

large amount of truth. The system that was in place in mid-1966 reflected changes

and compromises to doctrine that the realities of the situation in South Vietnam

necessitated. The Army’s concept of hospital support for a field army had

assumed that surgical and evacuation hospitals would move with combat units

and provide necessary medical services as the tactical units to which they were

linked advanced or retreated. Field hospitals, although mobile, were not linked to

tactical units but were designed to serve an area.

With no discernible front lines and a generally unsafe road system, the three

types of hospitals, originally conceived of as relatively austere mobile medical facilities, gradually became fixed installations containing increasingly sophisticated

medical equipment. Rather than following combat units and receiving casualties

through a conventional Letterman-style evacuation chain, the hospitals received

patients virtually always by airlift, either by medevac helicopter or fixed-wing transports, generally C–130s, C–123s, and the scheduled C–118s, or less frequently by

Air Force or Army Caribous (respectively C–7s and CV–2s). Patients were regulated generally in the air through the forward area regulating system, which used highfrequency (HF) single sideband radios to connect the appropriate Army medical regulating officer to the evacuation aircraft. The medical regulating officer was in contact with the helicopter unit and various medical facilities to which the patient might

be sent, depending on the urgency for treatment, the type of wound, and the availability of the appropriate skills at a given hospital.72 As General Neel points out, the

helicopter became a valuable tool for managing patient flow because of its ability

while in transit to ignore terrain features, its speed, and the availability of communications to direct it in ways that were responsive to a changing combat and medical situation.73 The conventional Army evacuation chain became largely irrelevant

because of the short distances to be traversed from combat areas to medical facilities farther up the chain and the speed with which medevac helicopters or other air143

The Modern Aeromedical Evacuation System Emerges from Vietnam
craft could move patients. Army division aid stations were routinely overflown to

clearing and collecting units or directly to hospitals, which it was MACV policy to

locate at a relatively central position, defined as a thirty-minute helicopter flight

from the expected point of injury, whenever possible.74

Wherever located, all medical facilities were vulnerable to enemy attack, and

all of South Vietnam was designated a combat zone.75 Consequently, no COMZ

existed in South Vietnam, and no in-country general hospitals could deliver longterm definitive care to the more seriously wounded. The feasibility of evacuating

casualties directly from Vietnam to the United States had been demonstrated in

1961 by one of Military Airlift Command’s (MAC’s) new C–135 jet transports,

but that was at a time when relatively few Americans were in South Vietnam and

none were deployed in combat roles. In 1965, as the patient flow from Vietnam

began to increase as a result of U.S. combat operations, MAC’s acquisition of the

C–141A provided a possible means to increase this flow of casualties directly to

the ZI. This potential raised serious military and medical issues.

From the Americans’ early advisory years, patients evacuated from Vietnam

were flown by theater airlift aircraft to Clark AB where they were either further

distributed to hospitals within PACOM or prepared for evacuation by MAC to the

United States. With growing numbers of U.S. casualties in the 1965–1966 period,

matching the sick and wounded with the most appropriate medical facilities

through effective medical regulation assumed a critical role. The forward area regulating system controlled patient movements in-country, and regulation out-ofcountry was initially the responsibility of the Far East Joint Regulating Office at

Camp Zama, Japan. In November 1967, this role was effectively decentralized to

a MACV branch in Saigon where requests received from regulating officers

throughout South Vietnam were consolidated and coordinated with casualty staging facilities and offshore hospitals.76

As U.S. casualties and evacuees arriving at Clark increased substantially during

1965 and 1966, General Westmoreland, the MACV commander, experienced the

classic concern of seeing his sick and wounded evacuated to places far from their

units. As the MACV surgeon at that time pointed out some years later, if all casualties who could not return to duty within MACV’s 15- to 30-day evacuation policy

had been returned to the United States, U.S. combat strength in South Vietnam would

have experienced a serious decline. (MACV occasionally changed the basic 15-day

policy to 30 days depending on bed availability and casualty flow.) MACV’s solution was to have the equivalent of approximately 31⁄2 general hospitals established in

Japan to receive and provide care to patients who could be expected to return to duty

within the 60-day evacuation policy in effect in the rest of the theater.77

The Effect of the Vietnam War on Aeromedical Doctrine

If the Army Medical Department had had to adjust its doctrine regarding hospital support of a field army and the chain of evacuation, the Air Force had been

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A History of Aeromedical Evacuation in the U.S. Air Force
forced to accept de facto changes in its tactical aeromedical evacuation doctrine.

Evaluating the period 1965–1968 when the evacuation system supporting U.S.

combat forces in South Vietnam developed, TAC expressed considerable concern

that the tactical aeromedical evacuation doctrine it had formed based on the

Korean experience and subsequent joint exercises was not being followed.

PACAF Manual 55–13 assumed in accordance with the Medical Service in Joint

Operations, the 1956 joint manual that laid out the three services’ agreement of

understanding about how theater aeromedical evacuation systems would operate

in the future, that the theater air commander of the joint command would have

responsibility for aeromedical evacuation. Additionally, a theater medical officer

and a joint staff, including a joint regulating officer, would issue general medical

policy to the several theater components.78

In the event, the MACV theater air commander—the Seventh Air Force commander, after February 1966—was never given this responsibility by the PACAF

commander. Nor was this practical because the 315th Air Division functioned as

the theater airlift organization, and it controlled a large portion of the available airlift capability usable for aeromedical evacuation based outside South Vietnam.79

Until late 1967, the 315th Air Division also controlled the 9th Aeromedical

Evacuation Group (AMEG) that had detachments and squadrons, including the

903d at Tan Son Nhut, stationed at eighteen different locations in the PACOM.

Fifteen of these organizations were in Southeast Asia, and the logic of the situation generated a move of Headquarters 9th Group to Clark in the Philippines and

an organizational change to place it directly under PACAF, with the PACAF surgeon having technical supervision for aeromedical evacuation in early 1968.80

The TAC report was essentially quite negative about what it saw as the

Army’s default assumption of a role in tactical aeromedical evacuation that doctrine had prescribed was the Air Force’s. The report pointed out that doctrine had

postulated the deployment of mobile CSFs to provide area control for the Air

Force–directed TAES, but none had been deployed until 1967, “too late to prevent

incursion by Army helicopter capability into the tactical aeromedevac role, thus

degrading the validity of future tactical aeromedevac doctrine.” The report also

noted ruefully, “the credibility of tactical aeromedevac doctrine and concept was

degraded by the absence of Air Force [mobile] CSFs in forward areas and successful casualty staging by standard medical facilities at rear Vietnam bases.”81 It

saw the importance of tactical aeromedical evacuation diminished by several principal factors, the first being that

Army helicopters are natural and available vehicles to perform

the Army role of battlefield casualty pickup. Army force concepts envision adverse weather aeromed helicopters assigned to

medical commanders. Furthermore, Army cargo helicopters

have, like tactical airlift aircraft, a casualty back-haul capability. A threat to tactical AME [aeromedical evacuation] is posed

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The Modern Aeromedical Evacuation System Emerges from Vietnam
by these features combined with the Army’s growing fleets,

their improving range capability, and the localized nature of

RVN [Republic of Vietnam] and expected future conflicts

[emphasis added].82

These criticisms must be read in the context of a stylized format for Corona

Harvest reports that asked authors evaluating what happened against existing Air

Force doctrine to provide bases for their recommendations of changes to doctrine.

Little question exists that the choice of words and critical tone of the TAC report’s

comments reflect continuing friction between the Army and Air Force over Army

aviation.

MAC and the Evolution of Intertheater

Aeromedical Evacuation

Interestingly, the TAC report also reflected a certain degree of frustration

with what it saw as MAC’s encroachment on the tactical aeromedical mission.

Technology, in the form of the long-range and fast jet transport, the C–141, helped

revive an old issue regarding the value of evacuating casualties by air. Using the

new C–141s able to carry eighty litter patients, MAC inaugurated four weekly

aeromedical evacuation flights in July 1966 direct from Saigon to selected hospitals in the ZI. MAC documents and some Air Force surgeons argued that the use

of the new high-speed jets to evacuate patients directly to U.S. hospitals would

permit fewer forward medical facilities and savings in personnel and equipment

while concentrating scarce medical specialists, allowing their skills to be more

efficiently used.83

This was an argument analogous to the one made by flight surgeons in the

late 1920s and early 1930s that aircraft ambulances would permit concentrating

medical resources in general hospitals in the COMZ by eliminating links and the

concomitant requirement for medical personnel in the chain of evacuation. The

difference in Vietnam was that technology had now advanced to the point when

the rapid transfer of patients to definitive care to the distant CONUS hospitals was

a practical possibility, assuming that patients could survive their transit without a

serious degradation in their medical conditions. Purportedly, Air Force Manual

2–1, Strategic Airlift, asserted that evacuating patients from “conflict area staging

points...including...battlefield pickup and evacuation from initial point of treatment to medical facilities within the combat zone” was a strategic airlift mission.84

Whatever MAC’s view of how aeromedical evacuation of casualties from

Vietnam should be regulated, it was basically dictated by the volume of patients

requiring evacuation offshore, which spiked at times of major battle85; the nature

of a patient’s wounds; and concerns for sustaining a patient’s condition, once the

C–141 entered the MAC inventory. Early negative experience with some of the

patients MAC evacuated directly to the United States caused the MACV surgeon

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A History of Aeromedical Evacuation in the U.S. Air Force
in early 1967 to direct that the determination of whether or not a patient should be

evacuated to the CONUS would be made neither in Army hospitals in Vietnam

nor the Air Force CSFs serving them; the decision would be made by theater hospital staff members, and then only after a patient’s condition had been sufficiently stabilized, a status that may not have been as clear-cut to a doctor as a layman

might think.

Extensive monitoring and reporting of patients’ conditions as they transited

PACOM bases, particularly through Clark, validated the soundness of the MACV

directive, but they highlighted once again a fundamental and persistent difference

between some senior medical officers in the Army and the Air Force about how

best to use aeromedical evacuation. The Army Medical Department basically saw

aeromedical evacuation as the best method for moving patients after they had

been stabilized from an evacuation or surgical hospital in the combat area to

definitive care, either in the rear area or, when necessary, to the CONUS. Rapid

movement from the battle zone improved troop morale, and if patients capable of

rejoining their units within the evacuation policy were retained in medical facilities near the front, the size of the Army combat force would not be progressively

diminished. Some in the Air Force, while believing that significant morale and

humanitarian benefits could be realized through aeromedical evacuation, also

believed that expanding evacuation to the United States for virtually all classes of

patients offered the significant additional benefit of sharply reducing the forward

medical support structure needed in-theater. The wounded would be given the

minimum emergency treatment necessary for their survival while being moved by

air, and airlift would also provide the means to return them to duty once they were

healed.86

The latter view was implicit in the Seventh Air Force surgeon’s response to

the draft MACV directive, a response that took issue with its premise and also

seemed to reflect irritation at the overtly Army cast to the ostensibly joint subordinate unified command. Regarding the MACV surgeon’s justification for changing the policy of the Army surgeon general, Seventh Air Force Surgeon Col. Earl

Brannon pointedly noted, “medical policy in the PACOM, including hospitalization and evacuation procedures is not dictated by the [army] Surgeon General, but

is established by CINCPAC with appropriate JCS guidance and with due consideration of component surgeon at CINCPAC and MACV level.”87 Apropos the new

policy, Brannon wrote that it appeared “these ‘changes of policy’ are merely gimmicks to increase the bed occupancy in the overabundant offshore hospital beds,”

and he had seen no evidence to substantiate the MACV surgeon’s claim that

patients did not withstand the short flights to Clark and Japan well, let alone the

much longer direct flight to the CONUS.88

Samples of the record of additional or reparative treatment by aeromedical

evacuees at Clark and elsewhere indicate that Brannon was simply wrong. Some

patients’ degraded conditions upon arrival at intermediate stops did require their

removal and further treatment at offshore medical facilities before they could be

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The Modern Aeromedical Evacuation System Emerges from Vietnam
sent on. Their numbers were generally small, and they varied depending on the

intensity of conflict and the resultant level of casualties in a given period.

According to the deputy hospital commander at Clark, approximately 4 percent of

more than 50,000 evacuees to Clark between the beginning of the war and the end

of 1968 were removed for additional medical care, although some medical histories suggest a higher figure. Whatever the average, what is true is that patients

who were removed were indicative of the difficulties that could occur with early

evacuation by air of severely wounded individuals. In virtually all cases, problems

discovered during the examination of evacuees by Clark medical personnel

(which were routinely conducted when an aeromedical evacuation aircraft

arrived) were not flight-generated, and patients had not been removed frivolously, as some in-country medical authorities seemed at times to imply.89

Comments about the Vietnam War always need to be qualified because its

nature changed over time, but a recent analysis of the reasons offered in response

to a query by Brannon’s successor in late 1967 for why twenty such evacuees at

Clark were removed offers support to these propositions. The analysis validated

the medical necessity of the actions and identified patients in this restricted group

who had received inadequate treatment of their wounds, and others whose baseline condition required further stabilization before they were evacuated. To the

degree that errors of judgment did occur, they were joint; some occurred at Army

hospitals, and some occurred at Air Force casualty staging facilities where

patients were received before they departed Vietnam aboard evacuation aircraft.90

Of course, some conditions necessitating patient removal and further treatment were the result of the natural evolution of a case as well as deterioration of

a patient’s condition from dehydration, sequela from soiled dressings, and so

forth. The effect on patients of early aeromedical evacuation became the subject

of continuing intensive study by PACAF and MAC surgeons because conditions

in South Vietnam continued to necessitate transferring the seriously wounded and

sick out of Vietnam. The introduction of the new C–141 jet transports provided

the means to move patients rapidly among different offshore hospitals and directly to hospitals in the CONUS.91

By the end of 1965, the C–141 had replaced the C–135B, which remained

the primary aircraft utilized for aeromedical evacuation in PACOM during the

remaining years of the war. In 1967, MAC C–141s also picked up an intratheater

task, replacing the PACAF-dedicated C–118s that had provided aeromedical

evacuation to Clark. Consonant with the development of what was essentially a

two-phase evacuation system—Vietnam to offshore hospitals, and offshore hospitals to the CONUS—by September 1968 MAC C–141s were conducting virtually all intratheater evacuation missions from Vietnam, which now included

Guam and locations in Thailand and Okinawa. Direct C–141 flights from Tan

Son Nhut and Cam Ranh Bay were established to Yokota AB in the Tokyo

region. USAF airlift operations had moved to Yokota because the runways at

Tachikawa were too short to accommodate jet aircraft. C–141 evacuation routes

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A History of Aeromedical Evacuation in the U.S. Air Force
from Yokota to the United States traversed both the Central and North Pacific

Ocean to Travis AFB, California. The mid-Pacific route included Guam and

Hickam AFB in Hawaii.92

For more equitable patient distribution across the country and to ease the

burden on Travis AFB, which was the primary West Coast aerial port of entry for

patients, C–141s also carried patients over modified polar routes to Scott AFB in

the Midwest and to Andrews AFB in Maryland, just outside Washington, D.C.,

with refueling stops at Elmendorf AFB in Alaska. MAC had its own aeromedical

evacuation organization in PACOM, the 10th AMEG, which was headquartered

at Hickam. The 10th deployed two AMESs, the 56th at Yokota, with an AECC,

and the 57th at Clark. The 10th Group and its squadrons had detachments with

AECCs at three points in Vietnam: Danang, Cam Ranh Bay, and Tan Son Nhut.

By 1969 patients were being segregated by destination on C–141s and were

being flown directly to western destinations other than Travis. MAC’s aeromedical staging facilities were at Travis and Scott. All other major patient transfer

points featured aeromedical staging facilities, but like the in-country CSFs (other

than the mobile CSFs that fell under PACAF’s 903d AMES), all staging facilities were units under the major command that operated the particular base medical facility.93 The system functioned well enough to indicate that coordination

among all these entities was effective, but the degree of parallelism between

PACOM and MAC aeromedical evacuation organizations nevertheless suggested that greater efficiencies could be achieved through organizational changes to

bring tactical and strategic aeromedical evacuation under a single controlling

entity. Aeromedical evacuation conferences attended by representatives from the

major commands made recommendations supportive of such a move. Merging

the MAC and PACAF AECCs at Clark, Tan Son Nhut, Cam Ranh Bay, and

Danang was initially delayed, but it was eventually implemented as a step in that

direction.

Vietnam and the Acquisition of the C–9 Nightingale

By the early 1960s, C–131s had been in the MAC inventory for almost ten

years. Although representing a major step in modernizing the domestic aeromedical evacuation system as it regained vigor during the Korean War, their deficiencies became more evident as attention focused on distributing casualties, especially when the C–131’s performance was compared with the C–141’s. The number of patients delivered at Travis taxed the capability of the C–131s and the older

C–118s to distribute casualties to domestic medical facilities. The older aircraft

had also required frequent maintenance-related RONs (remain over night), with

attendant patient delays and discomfort and higher operational costs. Studies in

the early 1960s indicated that a larger capacity jet aircraft specially configured for

aeromedical evacuation could be capable enough to operate on domestic routes

with many fewer RONs, shorter patient transportation times, and lower costs.94

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The Modern Aeromedical Evacuation System Emerges from Vietnam
150

A History of Aeromedical Evacuation in the U.S. Air Force
After a yearly series of intensive studies, the McDonnell Douglas DC–9, an

off-the-shelf jet aircraft used widely by commercial airlines, was procured and

delivered configured for medical operations. First introduced in October 1968, by

1969 it had completely replaced the C–131 and C–118 propeller aircraft in the

domestic system. Several years later it was deployed overseas. The C–9 configured to Air Force specifications cruised at 460 mph and had a maximum capacity

of 36 litter patients or a mixed load of 18 litter and 20 ambulatory patients. Given

its speed and capability, it could operate from a central location and fly domestic

routes without having to RON. The fleet of fourteen C–9s was placed under the

375th Aeromedical Airlift Wing at Scott. Deployed to the Pacific and European

theaters in the early 1970s, it provided a dedicated and efficient aeromedical evacuation aircraft that complemented the C–141 in a theater role. It provided the

means for MAC to argue that the Vietnam experience indicated a worldwide centralized aeromedical evacuation system under MAC was the most efficient

approach to future requirements in peace and war. How the AFRES, ANG, and the

CRAF might fit into such a system, if adopted, were acknowledged as issues, but

the result would remain to be seen.

Although justifiable on medical and efficiency grounds, C–9 procurement

was probably assisted by Army attempts in late 1963 to establish requirements for

medium-range transports for aeromedical airlift, which caused the Air Force to be

concerned that the Army’s aggressive aviation program would have as its next

objective taking over the domestic aeromedical evacuation system run by MAC.95

The Air Force might have been confirmed in its suspicions, rightly or wrongly, if

it had been aware that the chief nurse of the Army was proposing that eight Army

Nurse Corps officers be selected to train as flight nurses. Her justification was in

part that “Medical Support Plans for the future envision [the] use of large Army

cargo aircraft, both fixed wing and rotary wing types for the movement of groups

of patients, e.g., twenty-four litter and thirty-three ambulatory patients.”96

Conclusion

The adjustments of doctrine and practice that the war had imposed on the Air

Force’s tactical and strategic aeromedical evacuation systems were profound.

Although a resurgent aeromedical evacuation system with more or less distinct

intratheater and intertheater (tactical and strategic, in the new parlance) features

had emerged in the Korean War, it was basically a more sophisticated version of

the World War II system that had operated at its maximum innovation and greatest efficiency in late 1944 and 1945. Prewar concern about which patients could

be moved by air were largely dismissed on the basis of wartime experience, which

generally held that if a patient could be moved at all, he or she could be moved by

air. With the advent of large jet aircraft and under pressure to evacuate the sick

and wounded rapidly, the issue became more complex. Just what was sufficient

stabilization for a patient who was suffering from a variety of ills and who might

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The Modern Aeromedical Evacuation System Emerges from Vietnam
be exposed to lengthy times in the air was not necessarily clear. Air Force surgeons were well aware of the ambiguities medical personnel faced. A contract

study done for SAM explained:

The single word used to describe the patient’s condition in relationship to his ability to withstand evacuation is “stabilization.”

Originating physicians and physicians in general use this term

widely. However, when asked to define it in meaningful

terms...it becomes evident that there is no real agreed upon definition. It is most often utilized as a subjective term to describe

a patient’s condition modified by the urgency of the requirements to evacuate him.97

The positive aspect of any decision to evacuate a patient aeromedically was that

the patient would be transported to medical facilities incomparably better

equipped than those he might have found himself in in earlier wars.

The concept of using retrograde and essentially opportune airlift capability to

evacuate the wounded had been eroded by the absolute requirement that patients

had to be removed from the country, so more and more aeromedical evacuation

flights became scheduled flights, and more dedicated aircraft were adapted for

this mission. With Army helicopters having successfully co-opted the frontline

aeromedical evacuation role, the Air Force was increasingly forced to think in

terms of evacuation systems using high-performance jet transports that could

assume interchangeable roles.

Whatever discomfort any of the U.S. military services experienced when they

discovered that specific situations in wartime require adjustments to prewar doctrine, the system of aeromedical evacuation in Vietnam was a howling success.

The challenges and possibilities posed by new aircraft and requirements for evacuation also generated the development of new medical equipment. Typical of

items that could be installed on a cargo pallet and loaded on a cargo aircraft in

minutes was the Special Airborne Medical Care Unit, a module to increase the

capability of routine inflight medical care and allow for inflight emergency treatment of patients.98

Thousands of casualties were evacuated from the front lines principally by

Army helicopters, and PACAF and MAC evacuated thousands to offshore or

CONUS hospitals. The domestic system then distributed patients to hospitals providing whatever specialty care was needed. Selection criteria also considered a

desire to place patients as close to home as possible. The ANG showed its capability by assuming near-offshore work, freeing the regular domestic system so it

could transport Vietnam casualties. The modern aeromedical evacuation system

was beginning to emerge.

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A History of Aeromedical Evacuation in the U.S. Air Force
Chapter 7

MODERNIZATION, CENTRALIZATION,

AND NEW AEROMEDICAL

EVACUATION PARADIGMS

The last phase of U.S. involvement in Vietnam, the drawdown of U.S. forces

and the Vietnamization of the war, was precipitated by the Tet Offensive that

began on January 30, 1968. The aeromedical evacuation system that evolved during this final phase was a continuation of the system that had developed during

the first few years of U.S. involvement. Personnel turnover sometimes affected

how efficiently the system worked, but the evacuation routes, procedures, and

general nature of the system remained essentially unchanged.1 In 1968, the peak

year, MAC moved 60,770 battle casualties within the theater and from the Pacific

to the CONUS, but it moved only 8,183 in 1971, although the number of nonbattle casualties flown to the United States was almost the same in 1971 as it had

been in 1968.2 The size of the U.S. force had shrunk substantially in this period,

but the nonbattle casualty numbers remained high because narcotics addicts were

transported in patient status from June 1971, but not without some friction

between the Army and Air Force.3

As U.S. involvement in the war drew to a close, two noteworthy aeromedical

evacuation missions occurred: Operation Babylift, a humanitarian evacuation of

Vietnamese orphans, and Operation Homecoming, the return of POWs in accordance with the Paris agreement. Each was noteworthy, but Operation Babylift

became the prototype for MAC’s new aeromedical evacuation capabilities in

humanitarian missions in support of U.S. foreign policy.

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Modernization, Centralization, and New Aeromedical Paradigms
Operation Babylift

Although Operation Babylift used aeromedical personnel and facilities and was

accomplished in aircraft configured for aeromedical missions, it was more properly

a noncombatant evacuation. It was initiated in response to the obviously deteriorating military situation in South Vietnam in March 1975, when it became apparent

that Saigon and the South Vietnamese regime would be defeated by the end of April.

On the first day of April, the South Vietnamese ambassador to the United States

appealed for help in evacuating and resettling the large number of Vietnamese

refugees who would soon be fleeing the approaching communists. As an immediate

necessity, he cited the need to fly approximately 2,000 orphans to safety in the

United States or other friendly countries. Six private humanitarian agencies that

operated orphanages in South Vietnam had already determined they needed to get

their charges to safer locations. Two days later, the newly installed U.S. President,

Gerald R. Ford, released $2 million from a special foreign-aid children’s fund for

this purpose and directed that “C–5 and other aircraft especially equipped to care for

these orphans during the flight” be sent to Saigon. The President said he expected

such flights to begin within thirty-six to forty-eight hours.4

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A History of Aeromedical Evacuation in the U.S. Air Force

Col. Regina Aune,

heroine of Operation

Babylift.
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Modernization, Centralization, and New Aeromedical Paradigms

In spite of the lack of an explicit tasking from the President, Joint Staff Deputy

Director of Logistics Lt. Gen. Maurice F. Casey authorized MAC to conduct the

first two flights employing a C–5 Galaxy and a C–141 then en route to Saigon.

Because noncombatant evacuation was a State Department responsibility, Casey

secured a State Department agreement that MAC would conduct the orphans’ evacuation.5 In turn, MAC directed the 9th AMEG at Clark AB to provide aeromedical

evacuation personnel for the flights, but not to designate the flights as aeromedical

evacuation missions or to mark the aircraft with red crosses.6

The actual airlift of children and escorts was complicated by several factors

including a limitation on the number of U.S. personnel in South Vietnam imposed

by the ceasefire agreement. This initially precluded deploying a MAC airlift control element to Saigon, which normally would have regulated aircraft flow,

onloading, and dispatch, and provided a central point of control and coordination.

Lines of military authority overlapped in the theater, and close coordination

between DoD and the State Department was lacking. Adding to the confusion was

the uncoordinated entry into the evacuation process of privately chartered aircraft

contracted for on behalf of the humanitarian organizations operating the orphanages.

The general uncertainty surrounding the situation in Vietnam was also compounded unexpectedly by the personal intervention in the evacuation by the flamboyant president of World Airways, Ed Daly. World Airways had a number of

contracts for airlift with MAC, but Daly conducted what in effect was his own

unsanctioned private evacuation operation parallel to MAC’s, in disregard of

Federal Aviation Administration (FAA) regulations, the U.S. ambassador’s

authority, and the Status of Forces Agreement with Japan.7 Reportedly, when an

Orphaned children being loaded in Operation Babylift.
angry Daly asked the ambassador what he would do if, as the ambassador had

suggested might happen, Daly was shot down for taking off from Tan Son Nhut

without clearance, the ambassador answered simply, “Applaud.”8

The planned MAC use of retrograde airlift was to have begun with the C–5A

identified by General Casey in his directive to MAC Commander Gen. Paul K.

Carleton The intent was that subsequent missions would be flown by C–141s. The

selection of the C–5 was an accident of fate. Its cargo of 105-mm howitzers was

being delivered to Saigon as part of the Ford administration’s desperate attempt to

shore up the foundering Thieu regime, and the C–5 carrying the howitzers was the

first aircraft in position to embark the orphans after the President issued his directive.9

Unlike the C–141, C–5 aircraft, which had entered the MAC inventory in

1970, were not intended for use in aeromedical evacuation and had no stanchions

for litter installation. C–5s were designed to carry outsized cargo such as combat

vehicles, not passengers. However, each aircraft had seventy-five airline-type

seats in banks of three in a troop compartment at the rear of the fuselage, high

above the cargo floor and accessible only by a ladder. Theoretically, ambulatory

patients might be carried in this compartment, although climbing the ladder could

present a problem. When Lt. Col. Regina Aune, the medical crew director (MCD)

for the C–5 flight, who had been on alert at Clark for any C–141 urgent aeromedical evacuation, arrived at Tan Son Nhut, she described the situation as chaos.10

Neither she nor any of the other medical personnel had ever evacuated patients on

a C–5, but now they were to participate in airlifting 228 Vietnamese orphans to

Clark, where they would be medically screened and subsequently moved to the

United States for adoption. (Eyewitnesses reported that many of the children actually had parents who had put them aboard aircraft to get them to safety while they

themselves remained behind.) After processing, the children were to be accompanied by civilian escorts who were representatives of the Agency for International

Development (AID). Because too few passenger seats were available for everyone, the flight crew was authorized to load evacuees on the cargo floor. Children

and escorts were placed on blankets on the floor and held in place by heavy nylon

straps normally used to secure cargo. The troop compartment was filled, two children to a seat, with members of the flight crew and medical personnel passing

each child up the ladder. A double medical team of four flight nurses and six medical technicians was placed onboard to tend to the children in flight. The aircraft

took off with 314 persons onboard, including Dr. Meritt Stark, a civilian doctor

from the AID, and one of his daughters who was serving as an escort.11

The takeoff was routine, but as the aircraft reached an altitude of 23,000 feet,

a pressure door failed, causing an extremely rapid loss of cabin pressurization.

The explosive decompression was so violent that parts of the door assembly blew

off and severed the cables controlling the aircraft’s pitch trim tabs, elevator, and

rudder. The pilots were left with little control over the aircraft. Despite their desperate efforts, it crashed in a rice paddy near Tan Son Nhut, killing 138, including

78 orphans, a flight nurse, two medical technicians, and several other members of

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A History of Aeromedical Evacuation in the U.S. Air Force
the flight crew and passengers, including Dr. Stark’s daughter. Members of the

flight and medical crews acted heroically, including Lt. Col. Aune who, despite a

broken leg, helped evacuate the children until she collapsed. 1st Lt. Harriet

Goffinett, another flight nurse, suffered a broken collarbone that rendered one arm

immobile, but she still carried children on her opposite hip.12

Despite the loss of the C–5, Operation Babylift continued. Subsequent evacuation missions to the United States were made using a combination of MAC

C–141s and MAC-contracted civilian aircraft, including World Airways DC–8s

and 747s and Pan American Airways 747s. Unlike the instruction given to the 9th

AMEG, each of the C–141 missions was formally designated an aeromedical

evacuation mission and carried a standard medical crew. Ultimately, by May 9,

the official end of the operation, 2,894 orphans reached the United States, of

whom 1,090 were carried by privately contracted airlines.13

Beyond the obviously humanitarian aspects of Operation Babylift, the fact

remains that the relationship between MAC and the commercial airlines was

problematic and could affect the CRAF and its possible role in aeromedical evacuation. The difficulty was not attributable just to the somewhat bizarre conduct of

Ed Daly; commercial airlines complained to the State Department that in following President Ford’s directive, MAC was conducting an airlift that should be a

commercial operation.14 Another development with implications for future

aeromedical evacuation operations was that the necessarily rapid tempo—four to

five missions a day—of orphan evacuations from Saigon was such that the number of available medical crew members was quickly depleted, and they had to be

augmented with a continuing flow of flight nurses and medical technicians from

aeromedical evacuation organizations throughout the United States. It was necessary to reduce the standard medical flight crew to one flight nurse and two medical technicians for the flights from Clark to the United States, but a flight surgeon

was added to the crew for each flight.15 Finally, the lack of an AECC in Saigon

coupled with the absence of a single authority for airlift control meant that a substantial number of C–141 missions intended to evacuate orphans from Tan Son

Nhut on retrograde flights departed with relatively few. Civilian 747s chartered by

the humanitarian organizations that ran the Saigon orphanages arrived with no

coordination, and because they could and did transport very large numbers of

orphans, many fewer orphans were available for the C–141s because AID personnel could process only 400 a day. The result was a waste of in-flight medical

capability that the MAC C–141s provided, with a potentially negative effect on

the health of the orphans flown from Clark to the United States on privately chartered airliners due to their lack of trained flight medical crews.16

Operation Homecoming

Conducted between February 12 and April 4, 1973, Operation Homecoming

marked the formal severance of the United States from direct involvement in the

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Modernization, Centralization, and New Aeromedical Paradigms
fate of the South Vietnamese state. Withdrawal of remaining U.S. forces would

depend on the release of former U.S. and allied POWs from communist control,

and this release was to be accomplished within sixty days of the signing of the

Paris agreements. During the negotiations, plans had been made for this event,

whenever it might occur.17

The 9th AMEG at Clark had been tasked to conduct the repatriation and

return of the POWs as urgent aeromedical evacuation missions immediately upon

the prisoners’ release to U.S. control.18 Fortuitously, the sixteen flight surgeons

available proved to be exactly the number needed to cover the missions of the first

and second phases. Pursuant to a DoD directive, the POWs were declared patients

as soon as they returned to U.S. control. Unlike in the subsequent Babylift missions, the 9th was directed to designate the flights specifically as aeromedical

evacuations and to conduct them on aircraft marked with red crosses to ensure that

they accorded with the provisions of the ceasefire agreements.19

It was known that conditions for the POWs had improved over the years preceding the Paris negotiations, but earlier, much harsher treatment and difficult

conditions of life in North Vietnam prison camps in general meant that many prisoners would be suffering various types of mental and physical disabilities.20 The

limited medical intelligence available in planning for the Homecoming missions

led to the decision that two flight surgeons should be present on each mission, and

in some cases the standard in-flight medical crew was further augmented during

the actual operation by additional nurses and medical technicians. The number of

physicians needed to accompany the Homecoming flights was not readily available because there was no pool of unassigned military doctors. Those in-theater

had other existing medical responsibilities, so the solution was to recruit sixteen

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A History of Aeromedical Evacuation in the U.S. Air Force

Exultant ex-POWs ready for take-off as free men again.
Air Force, Army, and Navy second- and third-year residents in aerospace medicine to support these flights. The MAC patient movement priority system was as

follows: urgent indicated that immediate movement was required; priority meant

movement was required within twenty-four hours; and routine, movement was

required within seventy-two hours.21 Senior medical oversight was provided by

the Thirteenth Air Force surgeon, Col. Richard Malone, who flew to Gia Lam with

the advanced party (ADVON) to assist in conducting an initial medical screening

of the POWs, and Col. Leonard Johnson, commander of the 9th AMES, who coordinated the overall operation. Both men were board-certified Air Force medical

officers.22

Returning POWs were processed in three phases. The first 596 released were

collected at several points in Vietnam and flown on MAC C–141s and C–9s to

Clark AB where they were thoroughly examined by doctors. Then, generally

within seventy-two hours, MAC C–141s flew groups of 576 U.S. military personnel plus thirteen U.S. civilians and one Canadian civilian to one of five major

aerial ports in the United States. In the third phase, the evacuees were flown to one

of thirty-one destination hospitals within the United States on the 375th’s C–9s.

C–141s picked up the majority of the released POWs at Gia Lam Airport in

Hanoi, and the C–9s picked up ex-POWs of the Vietcong at Tan Son Nhut.

Although the North Vietnamese transported the POWs they held to Gia Lam, in

two cases forty-one POWs held by the Vietcong were flown to Saigon by Huey

UH–1D helicopters to be evacuated to Clark by C–9As. British helicopters flew

two POWs held by China to Kai Tak Airport for their flight from Hong Kong to

Clark.23 A C–130 carried the ADVON to Hanoi prior to the first mission, and each

ex-POW was assigned an escort for the flight back to Clark.24

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Modernization, Centralization, and New Aeromedical Paradigms

Freed POWs line up to board their return aircraft at Clark Air Base.
Although time did not permit medical members of the ADVON to conduct

extensive triage on the prisoners once they were released in Hanoi, medical intelligence had indicated specific medical problems that might be expected among the

evacuees. Appropriate medical equipment for these problems was provided

onboard or was stocked at Gia Lam. For example, intelligence had identified

approximately eight patients suspected to have cardiac disease, one of whom might

have suffered a heart attack in 1969. To anticipate a possible life-threatening situation during his evacuation, a flight surgeon/cardiologist and a senior medical technician with complete cardiac care equipment—an electrocardiograph; a batteryoperated defibrillator, cardiac monitor, and external pacemaker; and appropriate

cardiac drugs, including nitroglycerin to relieve angina, atropine to increase heart

rate, and quinidine gluconate to control arrhythmia—were placed at the Gia Lam

Airport by the ADVON C–130 awaiting this individual’s arrival because the timing of his release was unknown.25 On the evacuation flights from Hanoi, flight surgeons interviewed each patient and began documenting specific mental and physical conditions requiring further attention. They also provided treatments of various sorts, most of which were palliative, such as administering diazepam as a

sleeping aid and tranquilizer, analgesics for the pain of abscessed teeth and fractures, and antipyretics to reduce fever. They treated several cases of acute medical

problems while in flight. All medical data were transmitted to Clark by radio so

that appropriate treatment facilities might be prepared before the men’s arrival.

Each returning POW was provided with a seat and a litter to use as he wished.26

Operation Homecoming was a notable success. Perhaps because of the exhilaration engendered by their release, during the evacuation flights to the United

States, the released POWs generally paid little attention to medical conditions that

later required extensive treatment and rehabilitation. For example, in their collective report of the evacuation flights, the accompanying flight surgeons reported

that they noted numerous cases of poorly healed fractures and damaged joints

among the returnees. Others had medical problems generated by wounds. One had

suffered a head injury that induced epilepsy-type seizures; another had injuries to

his spinal cord from a land mine that almost totally paralyzed his lower extremities; a third had a massively swollen leg resulting from an AK–47 wound through

his knee. Among the returnees was one case of malaria and at least one case of

potentially severe psychoneurosis, and many manifested anxiety and hyperactivity. In this regard, the presence of flight surgeons on the evacuation aircraft proved

extremely helpful because most of the returning POWs were downed pilots or aircrew who felt comfortable with aeromedically trained physicians, and the

returnees sought them out to discuss their concerns and anxieties openly and

frankly. Virtually all ex-POWs had intestinal parasites which caused them great

concern.27

Operation Homecoming was an extremely heartwarming and satisfying way

for the United States to end its otherwise disheartening involvement in the

Vietnamese conflict. Two of the accompanying flight surgeons reported that

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A History of Aeromedical Evacuation in the U.S. Air Force
working with the ex-POWs was a most moving and meaningful experience, saying they would never forget the men’s faces and joy as they entered the aircraft.28

The operation presented immediate and potential lessons for future aeromedical evacuation operations. From an operational and medical standpoint, it had

been conducted with effectiveness by PACAF and MAC. The theater and MAC

aeromedical evacuation systems had performed extremely well, and the returnees’

extensive observations throughout the evacuation process provided a considerable

body of new data on the physical and psychological effects of being a POW. With

regard to recommendations to be drawn from a considered evaluation of the operation, participating Army, Navy, and Air Force flight surgeons collectively recommended that future joint operations transporting patients always include participants from all the services. They also recommended a clarification of lines of

responsibility that would clearly establish a Flight Surgeon Aeromedical

Evacuation Coordinator (the role played during Operation Homecoming by the

9th AMEG commander) as the controlling authority over all participants in the

aeromedical evacuation process. Perhaps the flight surgeons’ most portentous recommendation was that

future aeromedical evacuation missions of this magnitude

involving patients with unknown medical states and conditions

must include Flight Surgeons as part of the aeromedical evacuation crews [who] must be given ultimate authority in decision

making of clinical matters pertaining to the patients on such

special missions.29

Justified by the circumstances of Operation Homecoming, the recommendation

had obvious applicability to other special aeromedical evacuation missions

beyond the controlled but constrained circumstances of the POW airlift. Tactical

situations could preclude establishing evacuation facilities to produce stable

patients, or, as during the Tet Offensive, available facilities might be overwhelmed

by casualties requiring immediate evacuation.

The Tet experience is instructive in this regard, as one flight nurse recalled

many years later. Capt. Olivia Theriot was medical director of a crew staying

overnight near Tan Son Nhut before flying a scheduled aeromedical evacuation

mission to Clark the next day. During the night, up to three Vietcong battalions

attacked the airport while other Vietcong forces were attacking the city proper.

She and her crew were called out around 4:00 A.M. to evacuate the first casualties

from the fighting, and they began an aeromedical evacuation shuttle on C–130s

that lasted for three of the five or six days while serious fighting in Saigon continued. Casualties were evacuated on two roundtrip flights between Tan Son Nhut

and Clark; she and her colleagues then picked up the casualties who had been

treated at Clark and aeromedically evacuated them to Tachikawa. The patients

were either hospitalized at Tachikawa or further evacuated on MAC aeromedical

evacuation missions to the United States on C–141s. From Japan, medical teams

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Modernization, Centralization, and New Aeromedical Paradigms
were flown directly back to Tan Son Nhut to evacuate another load of casualties

to Clark for evaluation and treatment, and the cycle was repeated. Colonel Theriot

recalled that when she finally returned to her room in the bachelor officers’ quarters at Clark, one of the maids became very emotional, crying and embracing her

because in her absence it had been rumored that she had been captured in Saigon

by the Vietcong.30

Only basic triage could be accorded the evacuees at Tan Son Nhut to ascertain whether they were sufficiently stabilized to survive the approximately threehour flight to Clark. Too few doctors were available to augment the basic medical

crew of flight nurses and medical technicians and address whatever acute medical

emergencies might arise under the circumstances. Had flight surgeons been added

to the basic medical flight crew, they would have been extremely valuable, but as

was undoubtedly true during Tet (and Operation Homecoming would demonstrate

further), flight surgeons and possibly even basic aeromedical evacuation flight

crews could be hard to find.

Creation of the Worldwide Aeromedical Evacuation System

C–9As were deployed to the Far East and Europe in 1972 under theater control to replace the C–118s that had been performing intratheater aeromedical evacuation. Although the Air Force had procured these single-purpose aircraft reluctantly in the late 1960s, their capability provided additional support for airlift consolidation, a major MAC objective.31

MAC’s acquisition of the C–141A and its smooth integration into the MAC

airlift structure was key to the command’s effective support of U.S. forces in

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A History of Aeromedical Evacuation in the U.S. Air Force

C–9 Nightingale aircraft.
Southeast Asia. The aircraft’s systems for command, control, and communications, its traffic management and cargo and passenger handling characteristics,

and its maintenance and logistic support features proved invaluable. The versatility of the C–141A ranged from conducting strategic airlift of passengers and cargo

to and from the United States to intratheater airlift missions, including (at

PACAF’s request) aeromedical evacuation. This created some coordination problems between similar support structures for the strategic and tactical airlift systems that, in the case of AECCs at Cam Ranh Bay, had resulted in consolidation

of the systems. MAC thus began to press for consolidation of tactical and theater

airlift forces under its control. In its Corona Harvest reports on Southeast Asia

(and presumably elsewhere), MAC argued that “airlift is a continuum”; pointed to

“extensive parallelism” in basic functions of strategic and tactical operations that

“detracted from efficiency and tended to complicate” the totality of the airlift mission; and recommended consolidating tactical and strategic airlift assets under its

control to eliminate duplication and generate savings in both manpower and

equipment.32

The capabilities of the C–9A complemented those of the C–141A in performance and in the aeromedical evacuation role. Although the performance of the

four-engine C–141A was superior to that of the C–9A, both were high-speed,

long-range jet aircraft. The C–9A was dedicated to aeromedical evacuation, but

the C–141A could be quickly converted to carry litter and ambulatory patients. Its

medical capabilities were similar to a C–9A’s in that its palletized medical equipment and portable facilities could be put onboard in minutes using the C–141’s

integral cargo loading system. Moreover, the two aircraft had been interfacing

effectively in the aeromedical evacuation role at aerial ports of entry in the

CONUS since the late 1960s when the C–9A had taken over the domestic

aeromedical evacuation role. C–9As conducting aeromedical evacuation missions

in the European and Pacific theaters suggested the obvious parallel that MAC

operate the theater interfaces with strategic aeromedical evacuation, using the

CONUS interfaces as a model.

The MAC consolidation proposal was furthered by difficulties realized during the U.S. aerial resupply of Israel after it had suffered simultaneous attack by

Syria and Egypt in late 1973. The offense was a surprise violation of the UNsupervised ceasefire that had been in effect since 1967 when Israel had defeated

an Arab coalition. The Yom Kippur War, which opened with an attack on October

6, 1973, required that MAC conduct airlift operations over an average one-way

distance of 6,450 miles. Because Germany, Spain, Greece, and Turkey refused to

allow aircraft clearances, the aerial resupply operation, code-named Nicklegrass,

would have been very difficult, if possible at all, had Lajes AB in the Portugueseowned Azores Islands not been made available. This sobering realization led to

the development of aerial refueling capabilities in both the C–141A and the C–5.

The operation also revealed a break in the asserted continuum of airlift because it

showed that no procedures existed for TAC’s C–130s to augment the MAC sys163

Modernization, Centralization, and New Aeromedical Paradigms
tem in an emergency. Ad hoc procedures overcame this difficulty, but it brought

to light the difficulties of directing airlift through several commands. Against this

backdrop and the Southeast Asian experiences with duplicative airlift systems,

Secretary of Defense James Schlesinger, issued a directive on July 29, 1974, for

the Air Force to consolidate all military airlift forces under a single manager by

the end of FY 1977. A month later he identified the single manager as MAC.33

Subsequent directives from Headquarters Air Force specified further that MAC

assume responsibility for all aeromedical evacuation functions worldwide. It delegated responsibility for managing the new system to the parent organization of

the domestic C–9As, the 375th Aeromedical Airlift Wing, effective April 1, 1975.

The 375th thus took control of the 1st AMEG at Pope AFB, North Carolina, which

specifically focused on wartime and contingency requirements, and the 2d and 9th

AMEGs at Rhein-Main AB in Germany and Clark AB in the Philippines, respectively, which had responsibility for theater aeromedical evacuation in the U.S.

European Command (USEUCOM) and in PACOM.34

Among other benefits, this consolidation of aeromedical evacuation systems

provided greater flexibility in managing aeromedical personnel who could be

dual-qualified to achieve crew interchangeability on all aircraft able to be utilized

for aeromedical evacuation—C–9As, C–141As, or C–130s. This was already true

in MAC, as exemplified by Colonel Aune, the heroine of Operation Babylift.

Assigned to MAC’s 10th AMES at Travis, she was qualified in all three aircraft

when she was called out as the C–141A nurse at Clark to board the ill-fated C–5.35

A complete standardization of aeromedical evacuation policies, procedures, and

training could also be achieved, and staging locations and requirements could be

selected more efficiently to reduce medical crew fatigue. Medical crew rest

appears to have been a problem during aeromedical evacuation operations from

Vietnam. Initially and during heavy evacuation periods, like Tet and the 1969

offensive, medical crews were in short supply, and they were forced to fly very

heavy schedules and return quickly for additional evacuation duties.36

Aeromedical Evacuation in Europe: The NATO Commitment

Whereas the major events that conditioned the development of the modern

Air Force aeromedical evacuation system—the Korean and Vietnam conflicts—

paradoxically occurred in the Far East, the major national security problem facing

the United States after 1947 was the Soviet Union. It not only threatened U.S.

interests in Europe and elsewhere, but after the Soviets detonated their first atomic bomb, it threatened the territory and population of the United States itself. The

Cold War with the Soviet Union crystallized after the failure of the 1947 conferences to produce a peace treaty among the allied nations that had won World War

II. In 1949, after a communist coup in Czechoslovakia the preceding year had

destroyed any semblance of democratic government in that central European

country, the United States and twelve other nations signed the North Atlantic

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Treaty, thus creating NATO to provide collective defense against possible Soviet

aggression. The United States also made the unprecedented commitment to station its troops in Europe on a permanent basis, and it agreed to make them responsive to the operational command of a Supreme Allied Commander rather than a

national commander when certain conditions had been met.

A major element in shaping the evolution of the aeromedical evacuation system in the European theater was therefore quite different from what had influenced the 1957 creation of PACOM. U.S. occupation troops were present in

Germany from 1945 on, and in increasing numbers after 1949 as the United States

deployed troops to support its new treaty commitment. Medical support of U.S.

forces in Europe was readily available from U.S. military medical personnel,

some practicing in former German military facilities, and military medicine was

increasingly supplemented by the civilian medical community as the practice of

medicine revived in Europe. As one retired Air Force flight surgeon put it when

responding to a query about why there had been little aeromedical evacuation of

personnel from the fighter base to which he had been assigned in the Netherlands,

“There were hospitals every ten miles it seemed!”37

For this reason, aeromedical evacuation was much more focused on intratheater evacuation, moving patients from remote sites in Europe to the major facilities in Germany for treatment, than it was on intertheater, strategic aeromedical

evacuation to the United States.38 This pattern was intensified when Greece and

Turkey joined NATO in the early 1950s and the United States established bases in

these countries and others, such as Ethiopia, that had lesser-developed medical

infrastructures. Even before the DoD directed the use of airlift for patient evacuation in 1949, the overseas theaters had asked the AAF ATC to continue aeromedical evacuation to speed patients back to the United States and provide transport

for patients unable to travel by surface means. Army hospital ships were still

available, but they no longer operated under the Geneva Convention. They had

faster turnaround times now because only a vacant berth was necessary; having a

full patient load was no longer required.

In 1947, ATC’s commitment was to move 240 patients a month from the

Pacific theater to the United States but only 80 patients a month from the European

theater. This imbalance persisted throughout the postwar years, and the addition of

Vietnam casualties only exacerbated rather than fundamentally changed it. Only in

1947 did what had been an irregular, on-call aeromedical evacuation system supported by a reduced-strength 806th MAES go on a scheduled basis.39

With the formation of NATO, the prospect of casualties requiring evacuation

and treatment (a prospect always present once the Cold War began) became a formalized concern. Two medical planning conferences were held under the auspices

of NATO’s senior military headquarters, the Supreme Headquarters Allied Powers

Europe (SHAPE), in Paris in October 1952 and in June 1953. The U.S. delegation

included the Assistant for Health and Medical to the Secretary of Defense (this

position was later upgraded to the current post of Assistant Secretary of Defense

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for Health Affairs—ASD/HA), Dr. Melvin Casberg, the three military surgeons

general, and other senior officials and staff. Medical issues of common concern

discussed at the first meeting included basic principles of medical care, evacuation, and early treatment of battle casualties, topics based on the presentations by

U.S. representatives. Medical problems of atomic/biological/chemical warfare

were also discussed on the basis of presentations by representatives from the

United Kingdom. At the second conference, delegates sought to come to grips

with how to deal with medical issues within the complex structure of the NATO

military organization that was emerging, and they discussed SHAPE’s organizational, logistic, and medical planning. Delegates placed special emphasis on standardization projects and medical problems of atomic/biological/chemical warfare

defense. Deemed a success by Dr. Casberg, meetings were not scheduled to occur

on a preplanned basis; future meetings were left to SHAPE to call from time to

time at its discretion.40

From the paucity of later results, it appears that, for several decades after

these initial meetings, medical issues were left largely to discussion by national

representatives on the myriad working groups and subcommittees that the burgeoning NATO and SHAPE organizations were creating.41 NATO standardization

agreements that were produced addressed only broad conceptual issues such as

when to use antibiotics. Each nation’s military medical department was left to

practice medicine as it thought best for supporting its troops.42 Evacuation too

would be a national responsibility.

The prospect of full-scale conventional conflict with the Warsaw Pact and

heavy casualties with equally heavy aeromedical evacuation requirements tended

to lose relevance for NATO medical planning in the late 1950s. When new U.S.

hospitals were built in Europe during this period, their purpose was not to care for

casualties expected from a Warsaw Pact–NATO conflict, but to care for personnel

in SAC wings who were deployed to the United Kingdom to deter such an event.43

In 1957, under U.S. urging, NATO adopted nuclear deterrence as its strategic

concept and embraced a nuclear tripwire strategy. The approach was embodied in

MC 14/2, a policy declaration by the NATO Military Committee. The concept to

employ nuclear weapons agreed upon by the NATO members’ alliance had been

largely provided by the United States against the Warsaw Pact and Soviet Union,

should they attack any NATO member. It paralleled the Eisenhower strategy of

massive retaliation and was adopted after it became clear that the NATO members

had neither the resources nor the will to raise conventional forces sufficient to

match the Warsaw Pact’s assumed manpower advantage. The adoption of a flexible response strategy in 1967 altered the context for medical planning. Flexible

response rejected an immediate nuclear response to an attack in favor of a prior

robust conventional defense it was hoped would preclude the need to employ

nuclear weapons. The objective now became the need to think more seriously

about creating a medical support structure in Europe adequate to address the levels of casualties that a NATO–Warsaw Pact conflict would generate. Aeromedical

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evacuation within the theater and from Europe to the United States would be

important elements in such a structure, given the theater geography.

The creation of such a medical support structure would initially be slow

because of the high cost of our ten-year involvement in Vietnam and the desire to

reduce defense spending at that conflict’s end. Later, higher priority was accorded to strengthening our conventional combat power dedicated to the defense of

NATO. Territorially, NATO was relatively shallow between the inner German

border and the English Channel, and strengthening NATO’s capability to fight

conventionally was intended to reduce the possibility that it would have to employ

nuclear weapons to defeat a Warsaw Pact attack. To counter the Warsaw Pact’s

perceived superiority on the ground, the United States placed a great deal of

emphasis on rapidly reinforcing NATO with U.S. troops and their supporting

medical units from the United States. This would require large amounts of strategic airlift immediately following an attack. To ensure that reinforcements arrived

ready to fight, their equipment, including medical stocks, was positioned in

European depots so the forces could be combat ready as quickly as possible upon

arrival. Defense spending began to increase during the last year of the President

Jimmy Carter’s administration, and during Ronald Reagan’s presidency it expanded substantially with a number of initiatives intended to provide greater medical

readiness in Europe. Aeromedical evacuation played large in these initiatives.

Two events provided great impetus to these medical readiness initiatives: the

bombing of the U.S. Marine barracks in Beirut, Lebanon, on October 23, 1983,

that killed almost 250 marines, and the subsequent testimony before a congressional committee by the then-acting ASD/HA, Dr. John F. Beary. Beary testified

that only one of five wounded in a NATO–Warsaw Pact war could be treated,

given the inadequacies of U.S. military medicine in Europe, which provoked a

strong congressional reaction.44 His testimony reflected a certain amount of frustration with the apparent reluctance of the military services to fund medical readiness at a higher level, especially since defense budgets had increased in the early

1980s under the new Reagan administration.45 Beary’s replacement, Dr. William

“Bud” Mayer, a former Army psychiatrist, focused almost exclusively on medical

readiness, an emphasis that tended to reflect the administration’s focus on

strengthening the entire U.S. military. Mayer was apparently not very interested

in other issues such as dependent medical care and the costs of the peacetime military medical establishment, an issue that once again had given rise to a proposal

to integrate the service medical establishments into a common military medical

command, as Norman Kirk had favored in 1945.46

Mayer pushed even harder to increase the number of hospital beds that would

be available for casualties in a NATO–Warsaw Pact conflict or as a result of hostilities elsewhere where U.S. forces might become engaged. For this purpose,

some asserted with considerable reason that Mayer tended to exaggerate the deficiencies in the treatment capabilities of U.S. forces in Europe and the role of

ASD/HA in initiating the remedial programs through which most were being

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addressed.47 Mayer’s comments further highlighted long-standing problems and

may have helped garner congressional support for larger appropriations for medical readiness.48 His activities were obviously also intended to create pressure on

the service chiefs to fund more medical readiness measures in their respective

shares of the defense budget.49

Mayer’s ability to pressure the U.S. armed forces to increase medical readiness in support of their combat elements was rooted in the problems that arose

after the terrorist bombing of the U.S. Marine Corps barracks in Beirut. Criticism

was leveled at the treatment of survivors, including an accusation that service

rivalry had affected which hospitals the Air Force had sent the evacuated casualties to. An investigating commission headed by Adm. Robert Long concluded the

on-scene medical care after the bombing was heroic and stated it found no evidence that any of the wounded had died or received improper medical treatment

“as a result of evacuation or casualty distribution procedures.”50

The Beirut incident provided Mayer the opportunity to have Secretary of

Defense Caspar Weinberger task the ASD/HA (which was Mayer) to conduct an

independent review of medical readiness planning in USEUCOM. Weinberger

directed the secretaries of the Army, Navy, and Air Force and the DoD IG to provide support personnel to the review group when ASD/HA requested it and to pay

for their travel. Secretary Weinberger also directed the Chairman of the JCS

(CJCS) to arrange for USEUCOM cooperation and support of the review group

when it visited the European command.51 In a subsequent charge to the review

group, Mayer specified that as a minimum their investigation should cover “medical command and control, medical evacuation, the adequacy of friendly nations

for hospitalization and evacuation support in the event of mass casualties, and

planning for medical responses to terrorist attacks.” He enjoined the review group

members that they were in effect serving as extensions of the ASD/HA staff and

were representing the Secretary of Defense rather than their parent service or

command. He asked for their report by April 13, 1984.52

The resulting Zimble Report, as it came to be known after its putative author,

Adm. James A. Zimble, was extremely critical of USEUCOM’s medical readiness, particularly with regard to terrorism, which it referred to as nonmobilization

contingency planning. The USEUCOM staff believed the report to be an unfair

assessment because its conclusions were predetermined.53 In one sense, the observation was correct because Admiral Zimble’s foreword specifically stated that the

report essentially restated previously identified, persistent problems.54

The JCS directed the services to provide support for their own personnel,

inasmuch as there was no European command surgeon. The senior surgeon of

each component command—United States Air Force in Europe (USAFE), U.S.

Army Europe (USAREUR), and U.S. Navy Europe (USNAVEUR)—was designated USEUCOM surgeon in addition to his component command position. He

performed his theater-level duties on a part-time basis. The USEUCOM surgeon

had little or no formal operational control or line authority over the components’

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medical elements, and as the review group pointedly noted, his office was seriously understaffed, having only three officers and one clerk-typist.55

The Zimble Report organized its findings under ten headings based on Dr.

Mayer’s charge. The major thrust of the recommendations was that integrated

medical readiness planning which included involvement of NATO host nations

needed to be performed under the control of theater-level medical authorities.

Moreover, a full-time USEUCOM surgeon should have the authority to coordinate execution of the readiness plans in the event of war. The components’ parent

services were also to commit the necessary resources in their budgets to remedy

the well-known principal readiness shortfalls. Aeromedical evacuation was discussed in the Casualty Medical Evacuation section, and occasional references to

it appear under other headings as well.56

The Zimble Report’s discussion of aeromedical evacuation was cast principally in terms of the strain that shortfalls in theater medical capabilities would

impose on the ability of strategic airlift to meet the prescribed fifteen-day evacuation policy. The review group and the Office of the ASD/HA (OASD/HA) were

focused on procuring the necessary medical capabilities that in their view were

key to the adequate treatment of U.S. casualties. They did not, however, envision

enhancing aeromedical evacuation capabilities as the solution for the fundamental deficiencies in the theater’s medical readiness. From the perspective of the

OASD/HA, although the available aeromedical evacuation capabilities had some

problems, the number of C–141s was basically sufficient to provide strategic

aeromedical evacuation, and enough C–130s and theater-based C–9As were present to meet tactical aeromedical evacuation requirements.57 The review group’s

view clearly shared this perspective, concluding from their investigations that

it is clear that under the most optimistic assumptions we could

not provide life-saving treatment and stabilization for evacuation to the majority of our casualties in a major conventional

war in USEUCOM. This problem cannot be alleviated by shortening the evacuation policy, a step which affects only the movement of stabilized patients. Only the procurement of adequate

surgical capabilities can ensure that our casualties would

receive adequate treatment.58

The report noted that none of the services had programmed for sufficient intheater medical resources to support a fifteen-day evacuation policy during the

initial period of conflict. During this period of peak demand, third-echelon, or

reparative, medical care would be critically short for the first thirty to sixty days

of a European war, and a shortage of beds would dictate that only casualties not

stable enough to move be kept in-theater. The sizable number of injured who

might otherwise have returned to duty after short convalescences would have to

be evacuated to the United States to free beds for additional casualties. The review

group postulated that this would severely tax if not completely overwhelm MAC,

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whose aeromedical evacuation workload had increased by 29 percent worldwide

since 1978, and by 58 percent in USEUCOM since 1981, all the while it was facing shortages in airframes, crews, and medical equipment.59

Considering the shortage of in-theater medical capability to permit USEUCOM to meet the prescribed fifteen-day evacuation policy, the review group recommended that MAC continue to use ad hoc solutions and develop initiatives for

evacuating large numbers (3,000 per day) of relatively unstable casualties to the

United States under a five- to seven-day evacuation schedule. In an echo of the

Vietnam conflict, the group recommended that MAC inject its strategic airlift aircraft, the C–141A, into the TAES by moving small numbers of casualties who

could be emplaned quickly on retrograde missions from offload points in the combat zone to the theater COMZ.60

Other recommendations regarding aeromedical evacuation had more extensive

implications for doctrinal changes as well as for NATO policy regarding national

support of a member-nation’s forces. The review group recommended that planes for

each strategic aeromedical evacuation mission to the United States include a physician, not necessarily a flight surgeon, as an attendant; that MAC’s current efforts to

automate the huge amounts of patient data be speeded up and given a high priority;

that USEUCOM establish a high priority for negotiating additional host-nation support for medical evacuation in the combat zone, both on hospital trains and aboard

civil aviation; and that a study be initiated to identify and define the requirements of

a follow-on dedicated aeromedical evacuation aircraft to replace the C–9A.61

In spite of the fact that USEUCOM and Dr. Mayer’s office appeared to be

striving to achieve the same goal of higher medical readiness in the theater, especially after the issuance of the Zimble Report and the appointment of a new

activist deputy commander in chief of U.S. forces in Europe (DCINCEUR), Gen.

Richard Lawson, considerable tension existed between the theater and Mayer’s

office.62 It owed primarily to the fact that the theater had made greater strides in

remedying its medical readiness deficiencies than Dr. Mayer was apparently willing to acknowledge publicly.

The growth of the Warsaw Pact air threat in the early 1970s stimulated Air

Force Surgeon General Lt. Gen. Paul Myers to convene a high-level panel to consider how to improve medical readiness for a conventional war.63 The panel’s recommendations resulted in, among other things, a vigorous initiative led by Myers

to develop additional treatment facilities for Air Force casualties to support a

European theater evacuation policy of fifteen days. General Myers created a program for developing so-called contingency hospitals to provide additional beds

and ancillary services and equipment needed to care for the projected levels of

casualties. Suitably large unused buildings—hangars, abandoned hospitals, old

factories, and so on—were obtained in member nations of the alliance, including

Denmark, Germany, Great Britain, Luxembourg, and Turkey; similar arrangements were made quietly with Kenya, Israel, and France.64 These facilities were

rehabilitated, stocked with medical equipment and supplies, and held in standby

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status pending activation. When activated, medical personnel from the major Air

Force hospitals in the United States would be flown to Europe to make them operational while reservists assumed the domestic duties of deployed personnel. Key

to the system, once enough hospital beds were obtained, would be evacuation

capability within the European theater.

The contingency hospitals were generally large. Those at Little Rissington

and Upwood in the United Kingdom each had 1,500 beds; Nocton Hall, also in

the United Kingdom, and Donaueschingen in Germany each had 750. In 1993,

when all the projected host-nation agreements had been concluded and the contingency hospitals were completed, the USAFE contingency hospital system was

scheduled to provide 14,500 beds.65 The service hierarchy was generally supportive of this and other initiatives and provided a tenfold increase in funding for the

contingency hospital program in its first year.66

The question of hospital beds for the casualties of all U.S. armed forces from

any conflict in Europe was obviously a broader issue. The commander in chief of

U.S. forces in Europe (CINCEUR), Gen. Bernard Rogers, USA, who also served

as NATO Supreme Allied Commander, Europe (SACEUR), had to be concerned

with the medical readiness planning of all of his component service commands

because a NATO–Warsaw Pact conflict was expected to produce very high casualties. A congressionally mandated conversion of support to combat forces in the

late 1970s had a negative effect on medical readiness, whereas a decade later the

JCS issued a directive to increase by tenfold the previous estimate of the number

of casualties in a European war.67

Urged on by the OASD/HA and following the lead of the Air Force, which

had developed ATHs as part of the deployable medical system (DEPMEDS) program, the Army developed Warm Base systems and the Navy developed a counterpart fleet hospital system. The increased bed capacities represented by contingency and deployable hospitals were further supplemented by agreements with

allied nations (the host-nation support agreements), including Great Britain,

Germany, Portugal, and Spain, to provided beds in their own hospitals for U.S.

casualties. Germany also agreed to provide hospital trains and buses.68

The viability of all these plans obviously depended on the availability of

timely aeromedical evacuation. The geographic extent of the allied European

Command, stretching as it did from North Cape, Norway, to the southern shores

of Turkey; the offshore location of many of the fixed and contingent COMZ medical facilities; the uncertainties regarding NATO’s ability to retain air superiority,

still the sine qua non for aeromedical evacuation; and the certainty that the level

of violence would be extremely intense, should the Warsaw Pact attack, made

aeromedical evacuation the preferred evacuation method, both medically and

strategically.69 Mayer appeared not to understand that retrograde airlift on C–130s

or C–141As would not necessarily be sufficient to support the theater’s tactical or

strategic aeromedical evacuation requirements, and the NATO members’ small

airlift forces made any major assistance in this area problematic at best.

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Beginning in the early 1980s, studies of medical mobilization at the National

Defense University conducted by knowledgeable officers in residence at its various schools had raised serious questions whether MAC aircraft could successfully meet the strategic aeromedical evacuation requirements arising from a

European war. One such study published in April 1982 by the Industrial College

of the Armed Forces (ICAF) was prepared by a group of student officers who

were experienced in military readiness issues. Using computer-based simulations

and assumptions based on planning factors drawn from known deployment plans

and projected casualties, they concluded that the theater would actually operate

with a zero-day evacuation policy for the first three to four weeks of the war when

the most intense fighting and highest casualty rates would occur. Because medical

facilities in Europe were so limited, only the most severely wounded could be

held in the available beds until they stabilized sufficiently for evacuation to the

United States. The less severely wounded, who ordinarily would have been

returnable to duty within the evacuation policy, would have to be evacuated by air

from the theater to free beds for more of the severely wounded. The estimated

3,000 to 5,000 casualties evacuated daily in each of the first thirty days would

include up to 70,000 ambulatory wounded who might otherwise have been

returned to duty, and pressure on the relatively limited amount of strategic airlift

would overwhelm the aeromedical evacuation system.70

The situation would not necessarily improve in the near term because the

deployment of units and logistic support to reinforce NATO in accordance with

the JCS Operation Plan (OPLAN) 4102 would have higher priority than the

deployment of medical units and medical facilities. The authors calculated that the

91 C–141A retrograde missions daily required to transport 5,000 patients to the

United States would in turn generate a requirement for 31 missions from the

CONUS to the theater to return equipment needed to reconfigure C–141s for

aeromedical evacuation. This would add to the strain placed upon the already

overburdened strategic airlift system, which in any case would place lower priority on such missions during the initial period of intense combat.71

This situation had a certain irony because, contrary to the lack of military

medical facilities in Europe, sufficient hospital beds were becoming available in

the United States to handle the large numbers of expected casualties. In 1980, the

Secretary of Defense had directed the establishment of a civilian/military contingency hospital system that provided access to civilian and non-DoD federal hospitals for military personnel.72 Dr. Mayer’s office initially reacted negatively to the

1982 ICAF study, and its recommendations were accepted only after a personal

visit to the OASD/HA by the president of the National Defense University, an Air

Force lieutenant general.73

By the middle of the decade with the continued expansion of the USEUCOM

contingency hospitals and the additional beds made available for U.S. casualties

through NATO host-nation support agreements, assumptions on which the ICAF

study was based were no longer completely valid. Many still had salience, how172

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ever, including the problem of distributing patients by air to hospitals for definitive care once they had reached the United States. More critical was USEUCOM’s

tactical aeromedical evacuation capability, which the authors of the ICAF study

had deliberately not analyzed but which now assumed increased importance.

Although doctrinally the Army was responsible for evacuating casualties

within the combat zone and the Air Force was responsible for moving them from

the combat zone to medical facilities in the COMZ, France’s departure from participation in NATO’s integrated military structure tended to blur these distinctions. USEUCOM’s plan was to use all available means of evacuation, including

Army medevac and transport helicopters, German hospital trains and ambulance

buses, and C–130s to move patients to rear medical facilities, some of which qualified as COMZ facilities.74 In this phase of evacuation, MAC’s theater-deployed

C–130s were to play a major role by moving wounded on retrograde missions

from casualty collection points as far forward in the combat area as the tactical situation permitted to rear continental hospitals. From these hospitals, the five

C–9As based in-theater, with possibly some help from C–141s, would carry the

patients to offshore hospitals in the United Kingdom, Spain, Portugal, and other

points as contingency hospitals were brought on line or additional host-nation

hospital beds were secured.75 From these offshore hospitals, patients whose recovery periods exceeded the fifteen-day evacuation policy would enter the strategic

aeromedical evacuation system and be flown to the United States on C–141Bs.

Like the Army’s CH–47 Chinook helicopters, C–130s were tasked to provide critical airlift support to combat operations in the event of a Warsaw Pact attack, and

the conflict of priorities created great uncertainties regarding the availability of

tactical aeromedical evacuation by fixed- or rotary-wing aircraft.76

The solution was found in an initiative of the USEUCOM surgeon’s office,

which proposed that the DCINCEUR approach the MAC commander and ask him

to commit deployment of the eleven CONUS-based C–9As to the European theater to provide an additional dedicated aeromedical evacuation capability for

transporting casualties to the contingency hospitals. Based on analysis of projected casualty figures and staff-run computer simulations, the proposal was enthusiastically endorsed by the USAFE/USEUCOM surgeon, Maj. Gen. William

Greendyke. With the approval of General Lawson, the DCINCEUR, and his superior, General Rogers, the proposal was briefed together with the supporting analysis to the commanders of USAFE, USAREUR, and USNAVEUR, and according

to one member of the briefing team, every Army four-star general in the theater.77

Although the USNAVEUR commander, Admiral Smalls, expressed strong

reservations, the USAREUR commander, Gen. Glenn Otis, whose forces could

expect to experience the most casualties, together with USAFE commander and,

most importantly, General Rogers, the theater commander, approved making the

approach to MAC.78

The proposal was presented in the form of a letter from General Lawson to

MAC Commander Gen. Thomas Ryan, which General Greendyke carried per173

Modernization, Centralization, and New Aeromedical Paradigms
sonally to Ryan’s headquarters at Scott AFB. There he found the MAC commander receptive, although the MAC surgeon initially was opposed.79

In his letter, Lawson pointed out that, although USEUCOM had made great

strides during the preceding four years toward establishing a viable contingency

medical care system in Europe, it was still missing one critical link—a dedicated

capability to move patients within the theater in wartime.80 Lawson pointed out

that utilizing C–9As had operational as well as medical benefits. It could satisfy

more than 50 percent of USEUCOM’s tactical patient movement requirement for

the first thirty days while freeing C–130s for other critical wartime missions.

Additionally, with a dedicated system, theater medical planners had more latitude

in negotiating for additional wartime hospitals because they were currently

restricted to searching for sites near airfields programmed for heavy C–130 traffic in wartime.

The DCINCEUR acknowledged the additional challenge for distributing

patients through the domestic aeromedical evacuation system that would be created by sending the CONUS-based C–9As to Europe, but he candidly noted that,

if patients had to stack up anywhere, it was better that they do so in the United

States where multiple resources were available to provide medical services.81

Ryan responded positively to the USEUCOM proposal; subsequent joint

planning by MAC and USEUCOM medical planners resulted in General Ryan’s

successor, Gen. Duane Cassidy, accepting the proposal in December 1985.82 The

concept of operations (CONOPS) called for the C–9As to move patients between

third- and fourth-echelon medical care facilities in the relatively low-threat environment of rear areas, away from the combat zones. It was envisioned that ANG

and AFRES units would fulfill the domestic aeromedical evacuation function

once the CONUS-based C–9As had been dispatched to Europe.83

Conclusion

On the eve of the Cold War’s end, medical readiness in USEUCOM had been

brought to a high state of preparedness through the combined actions of aggressive senior command surgeons and the support of senior military commanders,

who had been pushed, not always in ways fully acceptable to the military, by the

OASD/HA. The first USEUCOM Strategic Medical Plan integrating the component commands’ medical planning had also been prepared under the direction of

the first USEUCOM surgeon to be appointed directly to this post.84 Underlying

these successes were the increased defense budgets of the Reagan era, which

made it easier for the armed forces chiefs of staff to choose between spending for

combat forces or for the medical readiness necessary to support them.

Discussions on how to meet the large aeromedical evacuation requirements

that a war in Europe could generate highlighted an issue to which MAC had been

devoting resources for some time: development of an aeromedical evacuation

capability in the CRAF. SAM had four current medical R&D studies in progress

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while USEUCOM was negotiating for use of the domestic C–9A fleet in the event

of war. The Boeing Corporation was also doing a study for MAC that focused on

the new wide-body passenger aircraft, the 767, and MAC was working with the

Army and other commercial firms to coordinate requirements. The MAC commander was heavily involved and pressed the MAC staff to develop a low-cost,

universal CRAF conversion kit that would permit the CRAF to provide aeromedical evacuation capability for both domestic and theater requirements.85

It would remain to be seen what effect the end of the Warsaw Pact threat and

the sudden collapse of the Soviet Union would have on the CRAF issue and further development of aeromedical evacuation doctrine and system capabilities to

support wartime operations. Small-scale contingency operations like Operation

Urgent Fury, the invasion of Grenada to rescue U.S. medical students in 1984, and

the evacuation of marine casualties from Lebanon in 1983 had revealed problems

in the aeromedical evacuation system during joint operations, which seemingly

had been transcended in USEUCOM by unprecedented cooperation among the

services in raising the command’s medical readiness in the 1980s.86 MAC’s strategic and domestic aeromedical evacuation operations would continue to operate

efficiently in their peacetime mode as the decade drew to a close, with 17,689

patients and attendants transported during 1989 on 877 aeromedical evacuation

missions by the 375th Aeromedical Airlift Wing.87

The blurring of the formal aeromedical evacuation structure in Europe and

the distribution of responsibilities that emerged as USEUCOM developed a high

state of medical readiness in support of U.S. forces in the theater began to impart

a different character to the aeromedical evacuation system. Aeromedical evacuation began to have a push aspect, in contrast to the carefully regulated nature of

the peacetime or doctrinal system that MAC operated. Staff members in the

USEUCOM surgeon’s office began to believe that carefully regulated patients,

which was the norm in the theater as the 1980s began, simply would not work

given the immense numbers of expected casualties.88

Removing patients from the combat zone to hospitals in the COMZ or to safe

havens as rapidly as possible began to seem more realistic. A logical corollary

would be to provide resuscitative care quickly, possibly while airborne, and abandon the more traditional mode of retaining casualties in medical facilities in the

rear of the combat zone until they were fully stable. Not without precedent—Tet

provided one within recent memory—this trend might or might not be applicable

to the evolution of aeromedical evacuation in a post–Cold War world. The nature

of the system that had emerged in the course of the 1980s was uniquely oriented

toward a single contingency—a large-scale war in Europe that would be extremely violent and produce large numbers of casualties—but it remained untested.

Whether this new paradigm was applicable to a different large-scale contingency

would remain to be seen.

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A History of Aeromedical Evacuation in the U.S. Air Force

The aftermath of the bombing of the Marine Barracks in Beirut, 1983.
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Aeromedical Evacuation in the New Era of Jointness

Chapter 8

AEROMEDICAL EVACUATION IN THE NEW

ERA OF JOINTNESS

Operation Urgent Fury, the U.S. invasion of Grenada, and the terrorist attack

on the U.S. Marines serving with the multinational force in Beirut, Lebanon,

occurred virtually simultaneously in October 1983. Aeromedical evacuation support in both cases was hampered by flaws in planning and in command and control. Formally joint, and in the case of Lebanon, also combined (loosely speaking

because the U.S. Marines were part of a multinational force), both operations

experienced difficulties in execution that had little to do with their opponents.

These difficulties stemmed largely from the weakness of the then-existing joint

mechanisms and attitude toward jointness, compared with the greater institutional roles of the U.S. military services and the service cultures within the military

decision-making processes.1 The imbalance was addressed radically and largely

successfully by congressional action in 1986 with the passage of the GoldwaterNichols Act (GNA) which strengthened the authority of the unified commands’

CINCs worldwide over their component Army, Navy, and Air Force commands.

(Illustrative of previous ambiguities perceived by CINCs, Adm. Robert Long,

investigating the terrorist bombing of the Marine Corps barracks in Beirut,

recalled asking General Rogers, the CINCEUR, why he had not done something

to improve the marines’ physical security following the earlier bombing of the

U.S. embassy in Beirut. According to the admiral, Rogers replied that he would

never dream of telling the marines how to do their job.2

) Perhaps most important,

provisions of the GNA firmly established the CJCS as the preeminent military

advisor to the Secretary of Defense, gave him control over the Joint Staff, and

imposed a jointness imperative upon the services by requiring that officers of all

services participate in joint professional military education and have a tour of duty

in a joint organization as a prerequisite for higher promotion.3
Although the invasion of Grenada had been successful under the unreformed

JCS system, Gen. Colin Powell, the second CJCS under GNA, characterized the

operation as a sloppy success, hardly a model of service cooperation. He noted in

his memoirs that only at the last minute was Maj. Gen. Norman Schwarzkopf

added to Vice Adm. Joseph Metcalf’s staff, who commanded the joint operation,

so his staff would have someone who understood ground combat operations.

According to Powell, “relations between the services were marred by poor communications, fractured command and control, interservice parochialism, and

micromanagement from Washington.”4 Planning and coordinating medical support and aeromedical evacuation were also fraught with problems. Powell might

have added that none of the combat forces initially knew that aeromedical evacuation personnel from the 1st AMES had established themselves on Barbados,

ready to evacuate casualties from the Grenada operation.5

By contrast, the next major U.S. military operation in which aeromedical

evacuation would have a prominent role, Operation Just Cause, the invasion of

Panama, occurred after GNA changed the JCS structure. This operation was successful and efficiently conducted. Medical support of the operation, including the

aeromedical evacuation of U.S. casualties, went so smoothly that the surgeon general of the Army at the time of the invasion, Lt. Gen. Frank Ledford, recalled long

after the event that he feared the successful arrangements by which medical support was executed might be seen as the paradigm for future operations for which

it was inappropriate.6

Operation Just Cause

The purpose of Just Cause, which was executed just prior to Christmas 1989,

was to arrest Gen. Manuel Noriega, head of the Panama Defense Force (PDF) and

effectively that country’s dictator, and bring him to trial before a U.S. jury. A

corollary objective was to dismantle the PDF because President George H. W.

Bush’s administration judged it to be so hopelessly corrupt and antidemocratic

that its continued existence would preclude any chance for the development of a

true democratic government in Panama. The previous Carter administration had

committed the United States by 1999 to relinquish control of the Panama Canal to

the Panamanian republic, so Noriega’s ascendancy began to be perceived by the

Bush administration as a threat to U.S. interests. Contingent planning for his

removal had begun in 1987, but it was his annulment of a presidential election in

May 1989, the brutal torture and murder of one of his enemies, his proclamation

of a state of war with the United States, and attacks on U.S. military personnel in

December 1989 that resulted in the death of a U.S. Marine officer that triggered

U.S. action.7

Operation Just Cause began in the early hours of December 20, 1989, with an

attack on key targets by more than 26,000 Americans, 10,500 of whom were

flown in from the CONUS. Army special forces and Navy SEALs and units of the

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Army’s rapid-response force, the 18th Airborne Corps based at Fort Bragg, North

Carolina, spearheaded the operation. The Air Force contributed airlift from MAC

for the initial deployment, including parachute drops on PDF positions at Rio

Hato and the Torrijos-Tocumen Airport. Continuing logistic support including retrograde aeromedical evacuation by Air Force AC–130 Spectre gunships from

MAC’s Twenty-third Air Force supported ground forces, and several of the thensecret F–117 Stealth fighters also made night attacks on targets that required

extremely accurate weapons delivery. (USAF units with the mission of supporting U.S. special forces were assigned from 1983 to 1990 to MAC under a new

Twenty-third Air Force.8) The JTF that conducted the operation was commanded

by Lt. Gen. Carl Stiner, the 18th Airborne Corps commander with a reputation for

toughness. A past commander of the Joint Special Operations Command, he was

handpicked for the job by the U.S. Southern Command (USSOUTHCOM) commander, Gen. Max Thurman.

Panamanian resistance was overcome fairly rapidly, although not without

U.S. casualties. Organized resistance by the PDF ended within several days after

a brief, though stronger than anticipated, opposition to more numerous and bettertrained and better-equipped professional U.S. forces. Isolated resistance continued

for several days, particularly from the so-called Dignity Battalions, units composed largely of untrained civilians supportive of Noriega and armed by him as a

civilian militia. USSOUTHCOM intelligence estimated that from 200 to 500

resisters still operated in Panama City on December 24. Although their effective

resistance ended the next day, it took until January 3 to apprehend Noriega, who

had taken refuge in the residence of the papal representative, the Nunciatua. In the

interim, Panamanian candidates whose election had been abrogated by Noriega

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The AC–130 gunship.
seven months earlier took office, and externally based U.S. forces began to withdraw. The operation had been a notable success for jointness, especially against

the background of pre-GNA operations. More important to the evolution of

aeromedical evacuation doctrine, the role that aeromedical evacuation played in

the operation inadvertently helped shape the outcome of a long-standing internal

discussion within the Air Force Medical Service. The issue was whether a physician should be placed onboard each aeromedical evacuation aircraft as a regular

member of the aeromedical crew, rather than continuing the practice of the past in

which physicians were assigned to special situations, like the strategic aeromedical evacuation of certain casualties during the Vietnam War. Augmenting standard medical crews for all missions would represent a major doctrinal change for

the Air Force since it became a separate service in 1947.9

Medical planning for the operation against Noriega was conducted for almost

two years and involved medical planners from the 18th Airborne Corps, 44th

Medical Brigade, 82d Airborne Division, 307th Medical Battalion, USSOUTHCOM surgeon’s office, and 1st AMES.10 The AMES was a former TAC unit that

had been reassigned to MAC when, in the mid-1970s, MAC was assigned worldwide responsibility for aeromedical evacuation. Based at Pope AFB, North

Carolina, on the Fort Bragg military reservation, the 1st AMES provided support

for the Army’s 18th Airborne Corps and other rapid-reaction units based there.11

A notable feature of the overall planning was the cloak of secrecy that was

placed over the operation and which had the potential to affect the aeromedical

evacuation aspect. According to the commander of the 1st AMES, Air Force

Medical Service Corps Col. Robert Brannon, security clearance requirements initially inhibited his ability to bring in all the medical planners. Secrecy was so tight

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The F–117 Nighthawk stealth fighter.
until Just Cause was launched that, when the decision to execute was made, the

375th Aeromedical Airlift Wing surgeon, to whom Brannon was responsible, was

not informed of the decision. Brannon’s immediate military boss was a line officer, the 317th Tactical Airlift Wing commander, also based at Pope AFB. Of the

three service surgeons general and their staffs, only Air Force Surgeon General Lt.

Gen. Monte Miller and selected members of his staff were involved in or even

aware of the medical planning for Just Cause. This was because the Air Force, and

specifically MAC, had responsibility for conducting the aeromedical evacuation

of casualties.12

Air Force Training Command Commander Lt. Gen. Robert Oaks was also

kept unaware of the operation until just before its execution. The plan called for

casualties to be evacuated by air to Kelly AFB at San Antonio, Texas, for treatment at the two major service medical centers in the area: Brooke Army Medical

Center, and the Air Force’s Wilford Hall Medical Center. The two facilities composed the San Antonio area Joint Military Medical Center which was commanded by a major general in the Air Force Medical Corps reporting to General Oaks.

Thus, when Oaks was told of the operation only two days before it began, he

thought the level of secrecy bizarre, particularly because he was enjoined to tell

no one on his staff about the operation, including the Joint Military Medical

Center commander, until one hour before its scheduled beginning at 1:00 A.M.

Panama time, or 0600 Greenwich Mean Time on December 20. However, Oaks

was able to get permission to brief selected members of his staff at approximately 9:00 the night before.13 The Air Force commander of Wilford Hall Medical

Center had also been informed of the operation shortly after Oaks, but he too had

been enjoined to tell no one, although he informed a key member of his staff, his

readiness officer, so to have the hospital prepared to receive casualties when an

alert could be declared.14

Aeromedical evacuation was the critical element in medical support of

Operation Just Cause. Although the Army had a major medical facility in Panama

City—the Gorgas Army Community Hospital—it was located near the PDF headquarters, the Comandancia, where fighting could be expected. Additionally, more

than 90 percent of the professional hospital personnel were Panamanian, and

whether they would be willing or able to report to the hospital for duty was uncertain. For this reason, the JTF commander, General Stiner, directed that during the

first seventy-two hours all casualties except those present in the immediate vicinity of Gorgas be aeromedically evacuated immediately. Once Gorgas was available, the evacuation policy was to be five days.15

Howard AFB became the focal point in Panama for the initial medical support of Just Cause and the point from which casualties were to be aeromedically

evacuated. The medical plan called for a joint casualty collecting point (JCCP) to

be established at Howard where casualties were to be triaged and given emergency medical care, including emergency surgery if necessary to stabilize them

clinically. Patients were then to be moved to a mobile aeromedical staging facili181

Aeromedical Evacuation in the New Era of Jointness
ty (MASF) to await evacuation to Kelly AFB, a flight lasting approximately three

to four hours.16 At Kelly, in accordance with a long-standing contingency plan,

triage would again be performed before patients were distributed for definitive

treatment to Wilford Hall or to Brooke. Wilford Hall was apparently designated

the primary medical treatment facility (MTF) because it was thought that more

effective control over the press would be possible there.17

Because the United States already had an authorized military presence in

Panama, additional military personnel and equipment were prepositioned at U.S.

Panamanian bases in discrete numbers and amounts that it was hoped would not

arouse Panamanian suspicions. Tasked to establish a TAES at Howard, Colonel

Brannon deployed to Howard from Fort Bragg with elements of the 1st AMES

and an Army forward-area surgical team (FAST) the day before the operation was

to commence. Brannon’s TAES included one AECC, one MASF, two aeromedical

evacuation liaison teams (AELTs), and twelve medical flight crews, totaling some

sixty-five personnel.18

By early afternoon on December 19, the MTFs and personnel at Howard

were ready to receive casualties. Brannon’s 1st AMES elements were augmented

with additional surgical teams and advanced trauma life support (ATLS) personnel from USSOUTHCOM resources. Twenty minutes after Operation Just Cause

began early the next morning, a large number of seriously wounded casualties

began to flow into the field medical facility at Howard. Arrangements for their

treatment were dictated by the tactical situation and General Stiner’s directive

rather than in accordance with current doctrine. The MASF tent was used as a

patient care ward in addition to its primary function as a staging facility. Due to

the restricted numbers of medical personnel at Howard, 1st AMES personnel were

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Howard Air Base, Panama.
required to work with the ATLS doctors to provide both litter support and mortuary monitoring in addition to their normal duties, which focused on evacuating

patients by air. Four operating room tables were used by two of the available three

FASTs as patients were stabilized for evacuation to Kelly AFB. At the start of hostilities the Army deployed several additional physicians and other medical personnel from various hospitals to Panama. Additionally, nine combat physicians

deployed with the special forces units from Fort Bragg, and at least some moved

to Howard to support the JCCP.19

Evacuees considered to be stabilized were breathing naturally, had any bleeding stanched, their fractures immobilized, and were adequately hydrated. To be

considered clinically stable, evacuees would require further surgical or other care

before they could be considered out of immediate danger. This situation concerned Air Force personnel because their doctrine prescribed that only clinically

stable patients should be aeromedically evacuated.20 Adding to the pressure to follow General Stiner’s directive to evacuate casualties as soon as possible was a

concern that the initial heavy flow of patients into Howard might continue and

overwhelm the base’s limited medical capabilities.21

The first casualties brought to the JCCP were mainly seriously injured special forces personnel, including Navy SEALs. Some had been wounded or injured

during the parachute drop at Rio Hato, where intense ground fire caused the drop

to be executed at a lower than planned altitude of 500 feet; others were casualties

of the drop at the Torrijos-Tocumen Airport where they encountered ground fire

during their descent.22 Of some 275 casualties who reached the JCCP, 257 individuals—216 litter patients and 41 ambulatory—were ultimately aeromedically

evacuated to Kelly, and the MASF evacuated 192 patients—162 litter and 30

ambulatory—in the first 24 hours. Forty percent of those evacuated to Kelly were

resuscitated or stabilized by the medical teams at the JCCP where 21 operations

including 14 abdominal procedures were performed. Of these evacuees, 38.8 percent had gunshot fragmentation wounds. Bearing on the issue of how to stabilize

patients most effectively for later definitive care, one analysis showed that the

debridement of open fracture wounds at Howard before evacuation to Kelly

resulted in significantly fewer infections than when such wounds were debrided

after the three-hour flight from Howard to Kelly. This conclusion tended to support an evolving view that the speed with which initial surgical care was provided was of greater importance for the survival of the wounded than the speed with

which the casualties could be aeromedically evacuated, as important as that might

be for their long-term survival.23

All but one of the nine flights carrying casualties from Howard to Kelly

between December 20 and 27 was made by medically reconfigured MAC

C–141s. In addition to patients evacuated to Kelly, four Americans killed in action

were flown out on the first two evacuation flights as an exception to doctrine. In

view of the unstable condition of some of these first evacuees, the first two

C–141s carried additional medical personnel to augment the regular crew of two

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flight nurses and three medical technicians. The first aircraft with some of the

most seriously wounded carried a surgeon and anesthesiologist; the second carried a medical technician and a flight surgeon.24

The initial load of casualties threatened to overwhelm the operating room

capacity at Wilford Hall, and the overflow patients were sent to Brooke.25 The

efforts of the staffs at the two hospital centers, combined with the skillful initial

resuscitation and stabilization efforts at Howard, succeeded in keeping mortality

among the casualties low. Two deaths occurred at the JCCP before the patients

could be aeromedically evacuated; a third occurred after arrival at Kelly. This last

one was a very badly wounded Navy SEAL who survived the flight to Wilford

Hall but died while undergoing surgery. Surviving evacuees received a number of

distinguished visitors, including the President. They were flown to medical facilities near their homes by the domestic C–9 aeromedical evacuation fleet supplemented by C–21s.26 The ultimate number of U.S. casualties during Operation Just

Cause was 23 killed and 322 wounded.27

The effectiveness of the TAES for Just Cause demonstrated positively the

total force concept, although the number of reserves utilized was relatively small.

By the end of 1989, more than 90 percent of the USAF aeromedical capability

resided in the Air Reserve Component (ARC), which includes members of both

the organized AFRES and the ANG. Responding to a request from Col. Brannon

Howard for augmentation, small numbers of aeromedical evacuation personnel

from the 31st AMES at Charleston and the 32d Aeromedical Evacuation Flight

from Kelly deployed to Howard within twelve hours.28

One significant issue largely obscured by the special requirements of

Operation Just Cause was medical regulation. Medical regulating, the assignment

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Marines on patrol during Operation Just Cause.
of sick and wounded military patients to MTFs for the next echelon of medical

care or for the definitive care necessary to ensure their recovery or rehabilitation,

has been the essential command-and-control element in the modern chain of evacuation since World War II. Matching a patient’s medical requirements with the

capability of the available hospitals at any given time is its core requirement.

Linking the MTFs are the patient evacuation system and all of the ancillary

actions performed by AECCs, which include scheduling patient airlift and preparing the manifests for the evacuation aircraft. Medical regulating in a joint environment historically has been a source of friction among the armed services, as

was shown in Vietnam when regulated patients were removed for medical reasons

at Clark AB. The principal reason is each service’s desire to ensure that its sick

and wounded are regulated to its own MTFs.29

For Operation Just Cause, General Stiner had essentially co-opted the medical regulating function by directing that casualties be evacuated immediately

after initial treatment to Kelly AFB, where they would receive definitive care at

either Wilford Hall or Brooke Medical Center. From these MTFs in the San

Antonio area, patients were medically regulated to other hospitals or convalescent

centers near their homes in accordance with medical criteria established by the

joint agency charged with this responsibility.

The joint patient regulating system was created in October 1950 by Secretary

of Defense George C. Marshall, who established the Armed Services Medical

Regulating Office (ASMRO) with authority and responsibility for the medical

regulation of all patients from all three armed services to and within the CONUS.

The ASMRO was located in Washington, D.C., and directed by the Army as

DoD’s executive agent. Its actual authority in practice initially was circumscribed

by various exceptions injected into the governing DoD directive by the service

surgeons.30 In June 1968, the Air Force estimated that ASMRO regulated less than

1 percent of all patients generated within the CONUS; by comparison, in 1967 the

Air Force itself had regulated some 15,000 Air Force–sponsored patients, threequarters of whom were active duty, among 112 Air Force hospitals and dispensaries.31

Theoretically, service preferences for hospitalizing their members in their

own MTFs could be accommodated in such a system if all services had a uniformly adequate medical capability including specialists within their medical

departments commensurate with the number of their members and casualty rates.

Such duplication or, more positively, redundancy, is vital from the perspective of

the different missions and operational plans of the military services. However, the

various commissions chartered to improve government efficiency, such as the

Hoover Commissions of the late 1940s and mid-1950s, have seen it quite differently, as have the OASD/HA and other civilian agencies concerned with costs.32

This same cost-consciousness has periodically been focused on the aeromedical

evacuation system by the use of audits that have resulted in restrictions on the flying hours devoted to aeromedical evacuation. One such audit in 1978 called for a

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50 percent cut in worldwide C–9 flying hours.33 Necessarily, medical regulating

and the aeromedical process have been inextricably intertwined.

From the USAF point of view, the ASMRO distribution of patients was

uneven from the beginning. In what is admittedly an extreme example, between

January 1952 and May 1953 ASMRO regulated 2,686 Air Force patients into

Army and Navy hospitals, but it regulated one Army patient and no Navy patients

into an Air Force hospital. Because the Air Force lacked a developed system of

specialty care in the early years after the creation of a separate Air Force Medical

Service in 1949, the service had no particular incentive to challenge this situation.

Most Air Force personnel regulated into Army and Navy hospitals in these early

years were cases that Air Force hospitals were neither staffed nor equipped to

treat, but it increasingly became an irritant in the joint regulating process from the

Air Force point of view as its hospital system grew. This was because its members were not being treated in their own service hospitals and because of the

undoubtedly adverse effects on its specialty and residency programs.34 The situation eased after the ASD/HA directed in late 1981 that ASMRO be collocated with

MAC’s aeromedical evacuation agency, the Patient Airlift Center (PAC) at Scott

AFB, in the interest of improving ASMRO’s wartime effectiveness. OASD/HA

also wanted the new ASMRO/PAC to rely on greater automatic data processing,

a goal that had concerned MAC’s PAC for some time.35

In the case of Operation Just Cause, medical regulation was obviously not

accomplished according to doctrine because the sending MTF, the deployed medical facility at Howard AFB, had no need to request that ASMRO designate a receiving MTF. However, ASMRO did regulate the subsequent distribution of patients to

hospitals near their homes. Operation Just Cause did not require regulating patients

with the automated Defense Medical Regulating Information System (DMRIS),

which was adopted in 1984 and by the late 1980s was in use within the CONUS and

USEUCOM, but not yet in PACOM. The special forces participating in the Panama

operation did not necessarily consider this an issue because their leadership was and

is constantly wary of having their troops identified.36

DMRIS constituted a sophisticated advance in medical regulating developed

under Air Force auspices. It reflected the interest in automating the aeromedical

evacuation process as represented in the 1960s by the development of the MAC

aeromedical airlift model. It was an attempt to devise a computer model that

would determine the manifests and itineraries for aeromedical airlift aircraft,

enabling the efficient transportation of military patients among certain CONUS

hospitals while providing a tool for analyzing and optimizing daily operations.37

Regulating patients worldwide was a greater challenge. As late as 1978, regulating requests were transmitted to ASMRO by message over normal communications systems, and a specific request and ASMRO’s decision to which hospital

the patient should be transported were entered into the computer database of the

Armed Services Medical Regulating Reporting System. Once a month, a lengthy

report drawing on data contained in the computerized database was distributed in

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A History of Aeromedical Evacuation in the U.S. Air Force
paper copy.38 By contrast, requests for medical regulating using DMRIS were

input to terminals that automatically compared the request with a database that

contained periodically updated information on hospital capabilities and bed availability. DMRIS then generated a regulating decision, which in peacetime could

produce manifests for the AECC to use in scheduling patients on appropriate retrograde or scheduled aeromedical evacuation flights.39

The DMRIS has two modes: peacetime and contingency. The former has

ninety-seven data elements about an individual patient, including name, to assist

the ASMRO with the regulating decision; the contingency mode has far fewer elements, and regulation is done by gross number only. In both modes, the principal

information concerns the patient’s wound or illness to facilitate identification of

the appropriate receiving MTF. In the contingency mode, the patient’s name is

excluded and his or her medical problem is coded against eight clinical categories.40 Although the peacetime mode theoretically permits tracking patients as

they move through the evacuation chain, because names appear in the regulating

requests and on aircraft manifests, the system cannot easily account for changes

in aircraft itineraries or other aircraft movements that are externally controlled.

Because patients’ names are not transmitted in the contingency system, it is

purposefully opaque and not capable of producing aircraft manifests. The system

lacks in-transit visibility of patients being aeromedically evacuated, negating the

services’ ability to track their sick and wounded or to respond to requests from

family members or legislators. In Operation Just Cause, General Stiner complained that the Army’s system for reporting casualties had been unable to match

the tempo of combat; as a result, the wounded who had been evacuated to San

Antonio were calling their families before they had been formally reported as

casualties.41

While medical regulating remained an open question with respect to combat

applications, the issue of physicians on aircraft tended toward resolution. A careful clinical analysis shortly after the conclusion of Just Cause by an Air Force

flight surgeon, Maj. Courtney Scott, cast doubt on the previous doctrine contraindicating aeromedical evacuation. Major Scott was stationed in San Antonio

at the time of the evacuation. While studying for certification in public health, he

took advantage of this opportunity to conduct in-depth research on the clinical

effect of aeromedical evacuation on the Just Cause casualties. His study provided

credible data that the inadvertent transport of unstable patients, on balance, had a

substantial positive effect, and that any negative effects on their survival and

recovery were relatively few. Notably, the most seriously wounded had survived

(with, he later admitted, a bit of luck), and many who would ordinarily have suffered amputations did not because an advanced microsurgery capability was available in San Antonio. The shortness of the flight to Kelly also factored in.42

The clinical implications of the Just Cause aeromedical evacuation process

heightened interest within the Air Force medical community in the concept that

physicians should serve routinely on aeromedical evacuation crews. MAC flight

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surgeons had augmented the initial C–141 aeromedical evacuation missions flown

in support of the Grenada invasion six years earlier, but medical support, like the

operation itself, was too haphazard in many respects to provide clear precedents.43

The situation in Operation Just Cause presented a paradox. The effective work of

the small group of medical personnel trained in emergency medicine and who

manned the JCCP at Howard, combined with the rapid aeromedical evacuation

that MAC provided to higher-echelon MTFs, seemed to demonstrate that transporting patients previously considered too unstable for travel by air could be clinically beneficial for the patient. The corollary to preventing patient deterioration

en route is to have onboard physicians to perform medical interventions beyond

the skill level and training of the normally present nurse and medical technicians.

Aeromedical evacuation of stabilized patients can also be beneficial to a commander in operational terms by clearing the battlefield and relieving him of the

necessity of supporting a large forward fixed medical presence and its concomitant logistic train. The Just Cause experience certainly suggested that this concept

was workable, at least for relatively small-scale contingencies like the invasion of

Panama, although not all evacuation flights carried augmenting physicians. Issues

remained about the applicability of moving stabilized patients in general war or

even large-scale contingencies, and doubters were found at very high levels.

General Ledford, the Army surgeon general, was concerned that the effectiveness

of the medical support of Just Cause would cause some to see it as a new paradigm with general applicability, rather than as a response to a unique situation.

General Miller and MAC’s aeromedical evacuation community still believed that

only completely stable patients should be moved by air. Within a year, this issue

would become acute because of the unexpected prospect of combat operations in

the Middle East.

Other Factors Affecting Aeromedical Evacuation in the 1980s

In addition to restructuring the JCS system to emphasize more effective joint

planning and operations by U.S. armed forces, GNA reforms had directly affected MAC and potentially affected the worldwide aeromedical evacuation system it

controlled. In 1987, MAC became the air component of a new joint command, the

U.S. Transportation Command (USTRANSCOM), which included the Navy’s

Military Sea Transport Service and the Army’s Military Traffic Management

Command. The MAC commander found himself dual-hatted as the commander

of USTRANSCOM, and although he now had authority to ensure that all forms

of transportation needed by the U.S. armed forces would be provided in a more

efficient and coordinated manner, he would always fulfill the role of the supporting CINC. The supported CINC—the unified commander who was assigned command of U.S. forces in the designated area of responsibility (AOR)—would

assign the priorities for the movement of men and materiel to his AOR. In a fastmoving contingency in an AOR with no major U.S. military presence, the sup188

A History of Aeromedical Evacuation in the U.S. Air Force
ported CINC’s first priority would undoubtedly be for combat units and their

equipment—bullets and bayonets—rather than for medical support. Although theoretically equal in status to other unified commands, USTRANSCOM would

have little direct impact on the aeromedical evacuation system, at least initially.

During its early shakedown years, the command focused on clarifying relations

with the Medical Service Corps and Military Traffic Management Command, and

it allowed MAC to conduct the aeromedical evacuation function with minimal

oversight until the Persian Gulf War. Not until February 1992 did

USTRANSCOM have authority over its components in peacetime.44

More significant for the further evolution of aeromedical evacuation was the

development of an aeromedical segment in the CRAF. The Congressionally

Mandated Mobility Study (CMMS) of 1981 recommended increasing intertheater

airlift capability, including enhancement of the CRAF, to rectify shortfalls in airlift capability for deploying troops and their equipment to meet the most likely

contingencies worldwide. The CMMS evaluated mobility requirements for four

representative scenarios: conflict in the Persian Gulf; a Soviet invasion of Iran; a

NATO–Warsaw Pact conflict; and confrontation in the Persian Gulf, with a precautionary reinforcement of Europe.45 Shortfalls in the aeromedical evacuation

capability required for these four scenarios using retrograde airlift were also identified. MAC would soon pursue expanding the CRAF as a partial answer to rectify both shortages.

The successful Greendyke-Lawson initiative of 1985 was an attempt to fill

the European theater’s portion of this shortfall with a dedicated resource for

aeromedical evacuation. Although MAC agreed to deploy the domestic C–9

aeromedical evacuation fleet to Europe to support the USEUCOM contingency

hospital system, this amount of strategic airlift was inadequate to provide the retrograde capability necessary to move the projected number of patients from

Europe to CONUS hospitals. Moreover, deploying domestic C–9s to Europe,

though critical to the viability of the emerging USEUCOM contingency hospital

system, would also create a severe shortfall in intra-CONUS aeromedical evacuation capability. During the Vietnam conflict, ANG and AFRES units had been

used to help meet domestic and near-offshore aeromedical evacuation requirements. These units were not equipped with the aeromedically configured C–9s,

and their use would have represented a degradation of aeromedical evacuation

capability. If a dedicated civil jet aircraft could be obtained from the CRAF and

configured with something approaching the onboard clinical capability of the

C–9, it would make an ideal replacement for the domestic aeromedical evacuation

fleet. If the CRAF could provide additional aeromedical evacuation capability to

ease, or ideally eliminate, the requirement that the C–141 fleet provide retrograde

patient transport, it would eliminate the requirement to configure C–141s for

aeromedical evacuation and then reconfigure them for normal airlift. It would

allow the C–141s to return directly to onload airfields for cargo and troops and

allow for greater flexibility in managing the airlift fleet.

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Aeromedical Evacuation in the New Era of Jointness
Throughout the 1980s, MAC had sought to increase participation of civil air

carriers in the CRAF because of the increased passenger and cargo airlift capability that additional civil aircraft could provide. By the end of the decade, the

effort had succeeded . Civil carriers had responded to increased financial incentives provided by Congress to place a significant number of additional commercial aircraft in the CRAF program.46 Attempting to augment MAC’s aeromedical

evacuation capabilities for contingencies by involving the CRAF was a logical

extension of MAC’s interest in CRAF’s cargo- and personnel-carrying capability.

The idea was all the more attractive because the airlines had begun to acquire the

new Boeing 767 wide-body aircraft that had extended-range capabilities. With

more than 90 percent of the USAF’s aeromedical evacuation personnel, flight

nurses, and medical technicians now resident in AFRES and ANG units, employing the reserve and Guard aeromedical evacuation crews on CRAF aircraft could

allow active-force C–141s and aircraft in associated reserve and Guard airlift units

to perform their primary airlift mission with greater flexibility. By the 1980s,

AFRES airlift organizations were being modernized, and a few had received

C–141s, but most were equipped with C–130s.

The actual development of the aeromedical evacuation segment reflected the

long interest of successive Air Force surgeons general and MAC surgeons in using

civil aircraft for aeromedical evacuation. The specific impetus came from a JCSdirected patient distribution study rooted in the need to address aeromedical evacuation capability deficits that the CMSS revealed. As early as 1983, SAM had

commissioned Texas A&M University to conduct a study of the feasibility of

using the CRAF for aeromedical evacuation. The study concluded that such use

was feasible, and it recommended a modular conversion system for the civil aircraft assigned to perform this mission.47

By the mid-1980s, SAM was conducting three additional R&D studies on

CRAF airlift and their aeromedical evacuation applications, with emphasis on

wide-body aircraft. Their efforts included studies for the design of interchangeable litter stanchions, tests of the stanchions, and a reconfiguration study incorporating the results of other studies to use in developing a modular aeromedical

evacuation system for the CRAF. The Boeing Company was also conducting a

study of adjustable litter stanchions for various-sized aircraft, and MAC was

studying the subject of dedicated aircraft for this purpose. MAC kept the Army

and Air Force surgeons general informed of its deliberations.48

The issue was complicated by the fact that the requirements needed to help

determine the size of the CRAF aeromedical evacuation segment were not yet

clear. The MAC surgeon noted that approval of the Army’s new concept of moving sicker patients more quickly—an interesting foreshadowing of the evacuation

arrangements for Operation Just Cause, five years hence—could affect evacuation

requirements. Additionally, MAC planners found the parameters the JCS had provided for the patient distribution study appeared unrealistic and insufficiently

detailed for the models they used to determine requirements. Importantly, the

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planners also discovered that these parameters did not permit them to quantify a

sufficiently significant requirement to justify procuring a replacement for the

nearly 20-year-old C–9 fleet, once it was phased out.49 Wary of JCS and Office of

the Secretary of Defense concerns about costs, the MAC commander directed that

modular conversion kits be developed with a focus on inexpensive portable medical conversion kits for the CRAF.50

Based on the promising results of the various studies, the MAC commander

formally recommended to the Secretary of the Air Force on November 17, 1985,

that a segment of the CRAF be dedicated to the aeromedical evacuation of casualties to and within the CONUS.51 The Department of Transportation subsequently approved MAC’s inclusion of an aeromedical evacuation segment in a future

memorandum of understanding on the CRAF. MAC then entered into a formal

agreement with the Aerospace Medical Division of the Air Force Systems

Command, the Air Force R&D agency, for the medical division to develop the

necessary aeromedical evacuation–unique hardware for the conversion kits. For

its part, MAC undertook to pursue contractual arrangements with civil carriers to

commit Boeing 767 and McDonnell-Douglas MD–80 aircraft to an aeromedical

evacuation role when an appropriate stage of the CRAF might be implemented.52

The initial plan called for MD–80s to replace the C–9s for domestic evacuations, with C–9s deploying to Europe in the event of a NATO–Warsaw Pact conflict. The 767 was to be used primarily for aeromedical evacuation from overseas

theaters to the CONUS. Once activated and reconfigured for this purpose, the aircraft were to remain so configured and dedicated for the duration of the emergency. Depending on when they were activated during a wartime emergency, the

CRAF aircraft could free much of the C–141 fleet from retrograde missions and

of the necessity to reconfigure their cargo and passenger airlift functions to those

of patient airlift.53

The conversion kits developed by the Aerospace Medical Division required

no permanent modification to an aircraft, merely the removal of the passenger

seats. The kits, designated CRAF aeromedical evacuation shipsets (AESS), consisted of four basic elements: litter stanchions that fitted into the tracks to which

the passenger seats had formerly been fastened; medical work stations for the

nurses; a therapeutic oxygen system to provide oxygen for each patient; and an

electrical power conversion capability to operate medical equipment. The oxygen

subsystem consisted of six 75-liter liquid oxygen supply containers installed in the

cargo bays, together with the electrical converters that changed the aircraft electrical voltage to one compatible with the carryon medical equipment used by nurses and medical technicians. With this system installed, the patient-carrying capacity of the 767 was impressive: the Boeing 767-200 could carry 87 litters and 26

ambulatory seats, or 111 litters and 2 seats; the 767-300 could carry 87 litters and

46 seats, or 111 litters and 20 seats.54

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Conclusion

The MD–80 was eventually dropped from the program due to potential problems with FAA certification of the liquid oxygen subsystem of the AESS, but by

the late 1980s, the 767 intertheater aeromedical evacuation program was very

much alive. Because the CRAF aeromedical evacuation segment would produce

the first use of civil and military crews flying on the same aircraft (the civil carrier aircrews were activated with the CRAF aircraft), MAC proposed that, when the

AESS were available, the scheduled C–141 flight from Rhein-Main, Germany, to

Andrews AFB be replaced with a Boeing 767. This would permit the gradual

qualification of military crews on the 767. Additionally, MAC proposed that the

Air Force surgeon general consider purchasing a Boeing 767 cabin mockup for

use at Brooks AFB where the aeromedical evacuation crews trained.55

As the 1980s ended, the AESS for the aeromedical evacuation segment of the

CRAF were completing development and going into production. Like the problem MAETS personnel faced during World War II with the C–54s, the high cabin

door on the 767s again raised the problem of how to lift litter patients to the level

of the cabin floor. In the previous situation, MAC had determined that the rear

cargo door of the C–141 should be at truck-bed height and level with the cabin

floor. It also developed special equipment, the 463L system, to eliminate loading

concerns in the C–141. However, this promised to be an issue of no great significance in view of MAC’s pre-Vietnam experience with C–118s. MAC appeared to

be well on the road to solving the shortages of aeromedical evacuation capability

that various studies since the early 1980s had indicated would be a detriment to

sufficient military readiness for countering a Warsaw Pact attack. Although the

development of aeromedical evacuation had moved positively into the new era of

jointness prescribed by GNA, it remained to be seen how the aeromedical evacuation system as part of this new armed forces structure would meet the major tests

of its capability. A potential problem might be a reluctance by the airlines to enroll

their 767s in the CRAF because these aircraft had become perhaps the airlines’

most profitable passenger carrier.

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Chapter 9

THE PERSIAN GULF WAR

TEST OF THE TOTAL FORCE

In the summer of 1990 the U.S. Central Command (CENTCOM) concluded

its annual wargame, a command post exercise codenamed Internal Look. The

exercise scenario was an invasion of Kuwait by its northern neighbor, Iraq, directed by Iraq’s powerful leader, Saddam Hussein.1 Within months, the scenario

became reality, and President Bush’s determination to restore the status quo produced the first real test of the United States’ total force concept. The test would

not only address how well active duty and reserve and National Guard combat and

combat support forces could meld and form a military force capable of achieving

U.S. objectives, it would also demonstrate how well the same mixture of active

duty and non–active duty personnel could provide a medical system capable of

supporting that force in the field. Because some 93 percent of the Air Force’s

aeromedical evacuation capability resides in its ARC, the test of the aeromedical

evacuation system was especially important.

The Context for Aeromedical Evacuation in the Gulf Crisis

The wartime role envisioned for the U.S. worldwide aeromedical evacuation

system had evolved in the decade and a half since the end of the Vietnam War into

a scenario primarily focused on supporting a NATO–Warsaw Pact war. In the late

1980s the United States had proposed that NATO create a NATO-wide intratheater aeromedical evacuationl system in which the European members would provide precommitted civil aircraft to the headquarters of the SACEUR, which would

man them with crews drawn from an international aeromedical force under

SACEUR’s command and control.2 By the summer of 1990, the Soviet Union was

in internal disarray, the Cold War had abruptly ended, and the possibility of a

NATO–Warsaw Pact conflict was remote. The U.S. public and Congress were

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looking forward to reduced expenditures for the armed forces that would produce

a peace dividend from the defense budget.

From the perspective of the chiefs of staff of the individual services, the issue

of medical readiness, for which civilian and military officials in the Pentagon had

successfully sought programmatic attention in the 1980s, now seemed of less

importance than their broader institutional interests. Their primary concern was

force reduction, which would bring the armed forces more into line with whatever threats continued to exist to national security in an international environment

no longer dominated by Soviet–U.S. rivalry.3 The prospect of force reduction and

a smaller defense budget elicited interservice tensions that continued, despite

GNA-mandated jointness.

Medical readiness issues, including aeromedical evacuation, lost visibility at

the highest levels of the U.S. military except the offices of the surgeons general.

There, readiness tended to be secondary to congressional pressure and pressure

from the DoD leadership to contain the costs of the military medical system.

Some of the increasing costs the system was experiencing were due to the changing nature of the military’s mixed constituency of active duty and retired personnel and military dependents. In 1960, the ratio of eligible civilians to active duty

military treated by the military medical services was 185:100; by 1990, this ratio

had grown to 327:100, making costs of benefits borne by military medicine

increasingly significant.4

At the beginning of the Persian Gulf crisis, the worldwide aeromedical evacuation system available to support a conflict in the CENTCOM AOR looked very

much like the system extant during Operation Just Cause at the end of 1989 when

the vast bulk of aeromedical evacuation capability resided with the ARC. Another

element of potential continuity in the late summer of 1990 was that the cadre of

the 1st AMES, which again would deploy first in a contingency, had recent experience in Just Cause, but whether the way aeromedical evacuation was conducted

during that operation would be applicable to another, larger contingency was not

at all clear.5

New, positive attitudes toward the idea of augmenting aeromedical evacuation crews with physicians to move unstable patients were beginning to develop

among some members of the Air Force medical community. Even before Just

Cause, unit type codes (UTCs) delineating the types of personnel required to provide operational capability in an aeromedical evacuation unit had been created to

require the inclusion of flight surgeons, although they had been assigned few specific functions to perform.6 According to a retired Air Force surgeon general, the

therapeutic results of the tactically driven aeromedical evacuation of unstable

casualties from Howard AFB during Operation Just Cause had tended to resolve

the long-standing debate within the Air Force medical community about moving

patients by air sooner after resuscitation or initial surgery. Flight surgeons or other

physicians could provide onboard medical intervention should a patient require it

during flight.7

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Air Force and MAC doctrine officially remained that patients aeromedically

evacuated would be stable, requiring nothing more than in-flight nursing care.

Should exceptional circumstances require the transport of an unstable, or a green,

patient who might require medical intervention while in flight, the Air Force stated that the MTF delivering the patient provide physicians or other specialized

medical care providers and that any required equipment, such as ventilators,

accompany the patient during flight.

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The Persian Gulf War: Test of the Total Force
The Military Context

Reports addressing medical support and aeromedical evacuation during the

Persian Gulf War are few.8 Because getting combat troops on the ground as fast as

possible was the emphasis, medical support not integral to the combat forces was

assigned a lower priority. On the eve of actual hostilities in February 1991, some

six months after the first U.S. deployments, medical support was largely in place

for the units originally deployed in what was codenamed Operation Desert Shield,

but by that date the size of the force had essentially doubled.9

UN-sanctioned military action against Iraq, christened Operation Desert

Storm, began with a massive aerial campaign against Iraqi targets on January 15,

1991. Strikes were made against a range of targets throughout January and into

the middle of February as a prelude to a planned ground assault intended to push

the Iraqis from Kuwait. The aerial campaign was totally successful, allowing the

coalition commander to move his forces far to the west in a strategic flanking

movement. In this position, he could mount a simultaneous assault into Iraq while

he attacked the Iraqi forces in Kuwait. The distance between these flanking forces

and the medical facilities established during Desert Shield now challenged medevac evacuation capabilities and emphasized the need for forward surgical capabilities to stabilize patients within the most efficacious period for initial surgical

intervention, the golden hour, prior to evacuation.10

Aerial attacks helped sap the resistance of many units in the Iraqi army, and

the coalition ground attack, which began on February 19, 1991, was spectacularly successful. It inflicted large casualties upon the Iraqis while U.S. forces and

their allies suffered surprisingly few. This outcome was unexpected because the

casualty estimates provided to CENTCOM medical planners had been extremely

high and promised to place great stress on the aeromedical evacuation system and

the medical facilities immediately supporting the ground combat forces. An average of 3,600 intratheater patient movements and 2,500 intertheater patient movements per day was projected as the maximun during the period of ground combat.11 Actual casualties during the initial days were expected to exceed the projected average because coalition ground forces would have to force their way

through what appeared to be formidable defensive barriers. These included extensive minefields, tanks and artillery dug in behind revetments, long earthen or sand

berms, and ditches filled with oil to be ignited when coalition forces attempted to

breach them.12

The rapidity with which Iraqi resistance collapsed and Kuwait was abandoned was consequently both welcomed and somewhat unexpected. An unanticipated result was that Saddam Hussein’s continuance in power generated a requirement for humanitarian intervention that included the use of aeromedical evacuation resources. Operation Provide Comfort was mounted to succor members of

Iraq’s Kurdish minority who were driven from their homes in northeastern Iraq

when Hussein reconsolidated his power after the war.

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The larger issue of how well the aeromedical evacuation system functioned

can be examined by addressing the following questions: What do accounts of the

system’s performance during the crisis reveal about how well the total force concept was realized with regard to aeromedical evacuation in the support of

deployed forces, and what impact would the lessons of the war have on the evolution of aeromedical evacuation in the USAF?

Utilization of the Medical Air Reserve Component

In contrast to the Vietnam War, reserves of all the services played a significant role in the Persian Gulf War. Nowhere was this more true than in medical

support. President Bush did not utilize his legal authority, the Presidential

Selected Reserve Call-up (PSRC), to call up to 200,000 reservists to active duty

until August 22. Even then, he directed the Secretary of Defense to limit the first

call to 48,000 personnel.13 Volunteers from the ANG and AFRES provided immediate augmentation to the small active duty aeromedical evacuation forces, and

large numbers of individual volunteers from the ARC began arriving in the AOR

early on to help establish an aeromedical evacuation system to support the deploying combat forces.14

The experience of Capt. Virginia Snyder, Chief Nurse of the ANG’s 142d

AMES, based at New Castle, Delaware, was typical. She volunteered for active

duty and was ordered to McGuire AFB where she was processed with a large

group of other volunteer flight nurses. On arrival at Riyadh on August 12, her first

impression was one of great confusion, a condition which Lt. Gen. William G.

Pagonis, the CENTCOM logistics chief, had also remarked upon three days ear197

The Persian Gulf War: Test of the Total Force

A wounded soldier being evacuated from the battle during Desert Storm.
lier. Told they would deploy to Al Kharj, she and her fellow travelers ended up at

Dhahran, where they were billeted in an old school.15

The Air Force also moved quickly with hospital support. Squadron medical

elements had accompanied the fighter squadrons, and the service quickly supplemented them with ATHs. The first arrived at Dhahran on August 12. It provided

the only U.S. military hospital facilities in the AOR for several weeks.16

Analyses of the course of Desert Shield and Desert Storm and their successful results have focused properly on the fact that the United States and its assorted coalition partners had some six months to prepare. Time was essential to provide both the forces and supporting logistic structure for Desert Shield and Desert

Storm, particularly because the adoption of the total force concept gave U.S.

reserve forces prominent roles in any national emergency. For the Army, this

meant integrating the previously designated and appropriately trained Army

Reserve and National Guard brigades with active duty Army divisions. Although

some combat brigades were not deployed during the Gulf conflict because of concerns that they were inadequately trained, various key support functions such as

civil affairs which had been eliminated in the Army’s active force and allocated to

reserve units were mobilized early in the emergency and deployed to the AOR.17

Aeromedical evacuation capability had not been completely eliminated in the

active Air Force, but like the Army, its aeromedical evacuation capability resided

overwhelmingly in its reserves.18 Unlike the ANG round-out brigades, aeromedical

evacuation personnel in the ARC were already extremely capable in their basic competency, that is, in-flight patient care aboard the tactical or strategic airlift aircraft on

which they trained. Medical personnel in the ARC also had more experience as flight

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Navy Lt. Devon Jones, left, runs towards the PAVE LOW that rescued him during

Operation Desert Storm. The 20th SOS conducted the first combat search and rescue

since the Vietnam War.
nurses and medical technicians, on average, than their active duty counterparts

because of the usual Air Force policy to assign graduates of flight nurse training to

only one tour of duty in their specialty. Medical technicians had somewhat more flexibility in that regard, but over their total careers on active duty they generally also had

relatively brief assignments to aeromedical evacuation crew duty.19

During the Gulf crisis, aeromedical evacuation personnel from the ARC

deployed initially as individual volunteers, and volunteers continued to provide

the core of the evacuation system in the AOR until the end of 1990.20 The first

involuntary call-up of aeromedical evacuation personnel from the ARC was not

done by units, but by groups of personnel and equipment from within various

ARC units. Although done pursuant to the President’s invocation of his statutory

authority on August 22, it did not occur until November 3.21 Then, the call-up was

done by UTCs, according to the three-letter alphanumeric codes assigned to

specifically designated personnel or equipment packages, each of which was created to perform a specified mission or portion thereof. MAC filled these aeromedical evacuation requirements by drawing upon different ARC units. In some cases,

MAC mixed individuals from different units and deployed them together to fill

existing UTCs; in others, it created new UTCs and filled them in the same way.22

This surprised and upset the ANG bureau and the AFRES, which always expected that entire units would be activated under this authority. What led MAC to activate by UTC was the desire to keep the U.S. presence in the AOR low, and unit

integrity received little concern.23

In December, continued Iraqi intransigence, the increase in the scale of offensive operations planned, and the larger casualty estimates made clear that greater

capability for both intra- and intertheater aeromedical evacuation would be needed and could not be filled solely by volunteers or by activating UTCs. MAC began

to activate ARC aeromedical evacuation units as entire units. Although seemingly more straightforward, this process was complicated by the fact that volunteers

already in the AOR could not legally be mobilized in place; they had to be

returned to the United States for mobilization before they could return to the AOR

and be assigned as needed.24

The Legislative Basis

The role played by ARC volunteers in supporting aeromedical evacuation is

special because the components continue to be the source of qualified personnel for

contingencies, large and small, in many scenarios. Legislation permitting the ARC

to be mobilized became law in 1952. It allows mobilizing any member of the

reserve component, with his or her permission. It neither requires a presidential declaration of national emergency nor invoking the PSRC statutory authority to involuntarily call up to 200,000 reserves, as President Bush did on August 22, 1990.25

The purpose of either a voluntary or involuntary PSRC mobilization is to

augment the active force for a specific mission. The voluntary option potentially

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provides augmentees for the aeromedical evacuation system until involuntary

call-ups of ARC personnel are made, but the medical planner confronts a certain

ambiguity when developing deliberate OPLANs because he cannot count on the

availability of ARC medical crews to meet the OPLAN requirements unless the

reserves are formally activated. In 1990, Air Force regulations had few guidelines

for accessing reservists or using volunteers,26 so the enthusiasm of ANG and

AFRES aeromedical evacuation personnel in the uncertain context of the Persian

Gulf crisis made the voluntary option extraordinarily valuable in meeting the

immediate need.

The Development of Medical Support Requirements

The lengthy interval between the UN resolutions and actual combat provided time for the forces to become acclimatized to desert conditions; to acquire

intelligence, especially target data, on which to plan both tactics and strategy for

the coming assault on the Iraqi forces; and to train to operate in the new environment.27 Similarly, the interval also provided time to develop a system of MTFs to

support the CENTCOM forces, although the facilities were not fully deployed

when conflict began. The development of the aeromedical evacuation system

reflected the changing CENTCOM mission, but it was always expected to play a

key role in the command’s plans for handling casualties incurred during combat

with the Iraqis.

In the initial weeks after Hussein’s forces invaded Kuwait, when it seemed

likely that Iraq would also attack Saudi Arabia, heavy U.S. casualties were

thought to be inevitable because U.S. force strength on the ground was small.

With essentially only first aid and emergency surgery available to the U.S. forces,

aeromedical evacuation would have been a principal means of saving lives.28 As

the Iraqis remained quiescent and U.S. strength grew, traditional Army medical

doctrine focused on return-to-duty and shaped the planning of third-echelon medical support for the deploying forces. The sick and wounded whose expected

return to duty exceeded the evacuation policy adopted for the AOR (initially fifteen days) would be evacuated to hospitals in USEUCOM which, according to

plan, would serve as the COMZ for the CENTCOM AOR. If necessary, patients

would be further aeromedically evacuated to the ZI. Remaining casualties,

excluding those capable of rejoining their units after first aid and brief stays in forward medical facilities, would return to duty following their recovery in hospitals

in the rear areas of the combat zone or in the COMZ.29

Should an extremely large number of casualties result after a ground assault

by CENTCOM forces on the Iraqis holding Kuwait, other considerations would

become critical. A large enough number of beds would have to be available in the

AOR to hold such casualties, and if a high casualty rate was sustained for any

length of time, these beds would have to be cleared of patients frequently enough

so that empty beds would be available for succeeding waves of the injured.

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Several physical factors would have to be taken into account in dealing with the

situation: first, and foremost, the estimated level of casualties; second, the number of patient beds and medical personnel and the amount of equipment that could

be deployed to the AOR, or perhaps be provided by Arab states in the Gulf region;

third, the capability of the aeromedical evacuation system to move patients from

the AOR to the COMZ rapidly enough to prevent an imbalance between the number of available beds and the number of new casualties arriving from the areas of

combat; and, fourth, the number of beds and medical personnel in the COMZ able

to receive and care for the evacuees.

Medically, there would be an issue of whether patients were air transportable—could they withstand the rigors of aeromedical evacuation during a

seven- or eight-hour flight to Germany and the United Kingdom? If they could not

be evacuated by air, the possibility existed that too few beds could be cleared in

the AOR. An imponderable factor shaping decisions about aeromedical evacuation was the threat to third-echelon MTFs in the rear areas of the combat zone

from Iraqi Scud missiles and the chemical and biological agents they might contain, the threat of which CENTCOM medical planners were all too well aware.30

With regard to beds in the AOR, the emphasis on readiness during Bud

Mayer’s tenure as ASD bore apparent fruit in Desert Shield/Desert Storm with the

Army’s DEPMEDS and the Navy’s fleet hospitals and hospital ships. The delineation of aeromedical evacuation responsibilities between the Army and Air Force

that had evolved from the Vietnam experience also tended to be accepted as doctrinally sound.31 Controversy during the Vietnam conflict concerning the roles and

missions of aeromedical evacuation was at least tacitly resolved by the Air

Force–Army agreement that essentially gave the Army exclusive control of

rotary-wing aircraft.

Staffing CENTCOM’s Medical Support System

Medical personnel to staff the facilities supporting CENTCOM were to come

from the reserves and ZI medical establishments, which all medical planners

assumed would stop serving non–active duty personnel during a national emergency. Any shortages in their staffs would be filled with reservists.32 USEUCOM

deployed approximately 2,000 active duty medical personnel to the Persian Gulf,

1,300 from the Army and 700 from the Air Force. The initial cadre of USAF

aeromedical personnel arrived contemporaneously with the first Army troops

from Fort Bragg. The first Army medical personnel to deploy were first-echelon

medical troops integral to the 82d Division and other units of the 18th Airborne

Corps. By the end of August, second-echelon Army medical treatment units also

began deploying. They were the 44th Medical Brigade, the 28th Combat Support

Hospital, and the 5th MASH. One third-echelon facility, the 47th Field Hospital,

also deployed.33 Only after the November decision to move the VII Corps from

Germany to the Gulf did additional third-echelon units begin deploying to the

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AOR from Europe and the ZI, although the CENTCOM surgeon, Col. Robert P.

Belihar, and others had been surveying the possible availability of medical facilities in Saudi Arabia and other potential host nations.

Deploying additional medical personnel from either the ZI or USEUCOM to

support CENTCOM had unexpectedly become more complicated as soon as the

President authorized involuntary mobilization of the selected reserve in late

August. To their great surprise, the service surgeons general were directed to

maintain staffing levels in their hospitals sufficient to provide the same level of

care to military dependents and retirees that they had been providing before the

crisis. Although this undoubtedly had some positive effect on the morale of servicemen dispatched to the Persian Gulf, the directive was largely motivated by

budgetary considerations. The intent was to help contain the costs of alternative

civilian medical care which would otherwise have to be paid for by the government’s Civilian Health and Medical Program of the Uniformed Services.34

The initial aeromedical evacuation capability in the AOR came from elements of MAC’s 2d AMES based at Rhein-Main AB, Germany. These personnel

deployed to Saudi Arabia on August 8, 1990, to provide a limited aeromedical

evacuation capability. Four days later the 1st AMES established the theater AECC

with 1st AMES Commander Col. Robert Brannon serving as both the AECC

director and the TAES commander.35 Brannon reported to the Commander, Airlift

Forces (COMALF), a MAC general officer, who in turn was responsible to the

joint forces Air Force commander, Gen. Charles “Chuck” Horner. Ten flight surgeons were also deployed to the Gulf region to help support the aeromedical evacuation system, although Colonel Brannon neither expected their arrival nor initially identified functions for them to fulfill under his command.36 Ultimately, their

potential worth would be demonstrated.

Staffing the Aeromedical Evacuation System

Personnel manning the initial aeromedical evacuation system established in the

AOR were overwhelmingly volunteers from the ARC; most were from ANG tactical

aeromedical squadrons. Their ANG training and experience was conducted aboard

C–130s, with which all but two ANG airlift units were equipped.37 Their tactical experience dictated that they would serve predominantly in the AOR, but many AFRES

aeromedical personnel whose units were assigned to Air Force bases with active and

reserve strategic airlift wings were deployed during Desert Shield to bases outside the

AOR to support the strategic system. The initial strategic crew capability in-country

was provided by volunteers from the 72d and 69th AMESs, AFRES units assigned to

McGuire AFB, New Jersey. These strategic crews made themselves available on

August 8 and arrived in the AOR on an L–1011 commercial aircraft three days later

with the other initial voluntary aeromedical evacuation contingent from the ARC.38

The process by which these volunteers were obtained from the ARC is a useful case study of the responsiveness and flexibility that ARC and the volunteer

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A History of Aeromedical Evacuation in the U.S. Air Force
system provide to the total force’s aeromedical evacuation component. MAC

formed a crisis response cell immediately after the Iraq’s invasion of Kuwait and

began to prepare for possible deployment requirements.39 It approached the

AFRES’s 69th and 72d AMESs at McGuire and notified each of a probable

requirement for ten strategic aeromedical evacuation crews. Each squadron identified ten crews and put them on alert, using previously allocated training days for

authority.40 At this time, the squadrons clearly expected that, if the requirement

became firm, their crews would be formally mobilized in accordance with the

PSRC authority.

The 1st AMES, the single MAC tactical aeromedical evacuation unit on

active duty, was alerted shortly after the invasion, and after discussions at MAC

headquarters, Colonel Brannon, its commander, began a confidential preliminary

survey of ARC units for possible help. Several days later, he informally

approached the ANG surgeon’s office by secure telephone to inquire how well the

ANG might be able to respond to a tasking from MAC for twenty-five tactical

aeromedical evacuation crews, twelve strategic aeromedical evacuation crews, an

AECC, and an aeromedical evacuation control element (AECE).41 His query generated a series of what-if telephone calls from Lt. Col. Paul McGuire of the ANG

air surgeon’s office to five ANG AMESs near the eastern seaboard—New York,

Delaware, Tennessee, West Virginia, and North Carolina—applying the criteria of

“proximity, immediacy, availability, and ability to provide the needed UTCs.” He

received very positive responses.42 Brannon had previously approached AFRES

headquarters with a similar informal query, but AFRES already had indicated to

the 1st’s tactical aeromedical evacuation unit counterpart in the reserves, the 37th

AMEG at MacDill AFB, Florida, that a requirement might come to mobilize its

members in support of a possible deployment to Saudi Arabia, so Brannon’s

queries seemed to be premature.43

When, instead of a presidential call-up of the reserves following the initial

deployment of U.S. forces, MAC requested volunteers to man the supporting

aeromedical evacuation system, virtually all of the twenty strategic aeromedical

evacuation crews at McGuire volunteered and deployed to the Gulf, arriving by

mid-August. Brannon was formally directed by MAC “to rapidly set up a tactical

airevac system in anticipation of going to war within two weeks for the defense

of Saudi Arabia.” The bulk of the other aeromedical evacuation personnel

required to supplement Brannon’s 1st AMES came from volunteers from the

ANG, mostly from the 142d AMES of the Delaware ANG, who arrived with him

in the AOR on August 11.44

Volunteers in large numbers from the ANG and AFRES responded to the

AMC initial tasking, and both organizations continued to provide volunteer personnel to operate the aeromedical evacuation system throughout Desert Shield as

it evolved under the direction of Colonel Brannon and his staff.45 These volunteers

were rotated periodically, with ANG personnel generally remaining in the AOR

for an average of forty-five days. As a result of these rotations, by the end of the

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year the vast majority of aeromedical personnel in both the ANG and AFRES had

served in the AOR.46

Oriented for years to supporting OPLAN 4102, the reinforcement of Europe,

and with only partially validated time-phased force and deployment data to support plans for moving CENTCOM forces to the Gulf region, medical planners

successfully resorted to ad hoc methods to conduct the actual activation and

deployment of the required personnel.47 Because the AOR lacked the rich military

and civil infrastructure present in Europe, deploying military units could no

longer draw on the dense military and civil communications networks present in

Europe to link their units to relevant command and control (C2

) and logistic systems, nor could strategic aeromedical evacuation be supported by a large number

of major airfields. Determining where to locate personnel in the AOR to operate

the TAES would depend largely on where U.S. ground forces deployed and where

they would be engaged in combat operations, should the CINC order them. Here,

geography could affect doctrine.

Factors Shaping the Chain of Evacuation

In contrast to Vietnam where the AOR was relatively small, distances in

CENTCOM’s AOR from the Kuwaiti border to the rear areas and some third-echelon MTFs were quite large. Distances from casualty pickup points were small

enough in Vietnam that medevac helicopters could and did overfly second-echelon MTFs directly to third-echelon facilities—evacuation and field hospitals—

and the average time from patient pickup to delivery to a medical facility by Army

medevac helicopter was thirty-five minutes.48 By contrast, in the Gulf, the commander of the 44th Medical Brigade worried that the U.S. forces, already more

than 200 miles into the Saudi Arabian interior at the beginning of the strategic

flanking attack, might outrun their medevac support capability, given the rapidity

with which armored forces had demonstrated historically they could advance in

desert warfare.49 The 18th Corps penetration of Iraq occurred approximately 225

miles west of the Persian Gulf coast and 370 miles north of Riyadh.

Whereas the Army concentrated a large number of hospitals—MedBase

America was within twenty-five miles of King Khalid Military City, some sixty

miles from the Kuwaiti border—other CENTCOM military treatment facilities were

dispersed widely.50 During Desert Shield and the air war, the Army’s 46th Combat

Support Hospital was located in mideastern Saudi Arabia, some 150 miles west of

Dhahran, the principal aerial port of debarkation in the Saudi kingdom for troops and

equipment.51 During the ground war, the 46th moved from the coast of the Persian

Gulf south of Kuwait to a position west of Kuwait, a hundred miles north into Iraq.52

From Riyadh, where the AECC was located, the Kuwaiti border was almost

300 miles away, and the Air Force contingency hospital at Seeb in Oman was

almost 1,000 miles distant. Air Force ATHs were scattered over Saudi Arabia near

airfields, from King Khalid Military City to Taif and Jeddah, more than 500 miles

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from Riyadh across Saudi Arabia, on the Red Sea. The Navy’s Fleet Hospitals 5

and 15 were located near each other at al-Jubayl (Jubail) on the Persian Gulf coast,

nearly 120 miles south of the Kuwaiti border and 240 miles east of Riyadh. At

such distances, the unrefueled range of Army medevac helicopters posed problems. The Huey helicopters’ range was less than 200 nautical miles, and the newer

Blackhawks could fly roughly 250 nautical miles on internal tanks.53

Potential difficulties were exemplified by the 332d Medical Brigade, a

reserve Army medical unit that deployed to the Persian Gulf in late November to

support the VII Corps arriving from Europe. The 332d was composed of fifteen

hospitals: five MASHs, five combat support hospitals, and five evacuation hospitals. When established in the AOR, the brigade’s forward hospital units were

approximately 150 miles away from third-echelon evacuation hospitals, a distance that would have required the medevac helicopters (85 percent of them

Hueys) to refuel at both ends of the flights between the front and rear hospital

facilities. Forward-area refueling points were established, but they were sometimes difficult to find in the desert, particularly at night,54 and refueling could

impose additional stress and transit times on patients. From the perspective of the

brigade commander, Brig. Gen. Michael Strong, even with the availability of

faster, longer-range Blackhawks, the kinds of distances his hospitals had to deal

with made medical evacuation “extremely difficult and very tough to coordinate.”55

As in Vietnam, Air Force tactical airlift filled gaps in the evacuation system

when it moved patients among the many fixed hospitals to the debarkation ports

for aeromedical evacuation. In the Persian Gulf AOR, C–130s provided a broader spectrum of evacuation capabilities than had originally been contemplated, but

the capability of the TAES to move patients from second- to third-echelon hospitals was especially important. Given Navy and Marine Corps doctrine to rely on

opportune helicopter lift to evacuate patients, the availability of the Air Force

C–130s would have proven essential had the marines suffered a high casualty rate

and only their CH–46 Sea Knight or CH–53 Sea Stallion helicopters been available for medevac. The use of C–130s for evacuation forward of second-echelon

medical units was also considered and actually conducted in support of some special forces units inside Iraq. The use of C–130 aircraft for casualty evacuation was

also contemplated by the commander of the medical group designated to provide

medical support to the 18th Airborne Corps when General Schwarzkopf’s lefthook forces penetrated far into Iraq.56

Uncertainties surrounding medevac generated a certain amount of frustration.

Fourteen months after ground combat ended, one veteran of medical service in the

AOR offered his opinion to an audience of fellow veterans:

We had the greatest capability to provide the definitive medical

care in theater that we ever had before, [but] at the same time

we had an almost non-existent capability to transport the

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[inaudible] line soldier, Marine, service person to the next level

of medical care.57

Although his first proposition was somewhat hyperbolic, his second accorded

substantially enough with the experience of others in the audience that he was not

challenged and was, in fact, echoed by some.58

As increasing numbers of U.S. combat forces and combat support forces

deployed to the AOR, the medical structure needed to support them, particularly

third-echelon MTFs (where theater evacuation policy became a consideration),

did not deploy until late in Desert Shield. One of the CENTCOM medical planners estimated that as the January 15 deadline approached, U.S. medical forces

were only 50 percent ready.59

There were exceptions. Two U.S. Navy hospital ships, USNS Comfort and

USNS Mercy, arrived in the AOR in mid-September. Each was capable of providing 1,000 beds, of which 100 constituted an intensive care unit and 400 were

devoted to acute care. Each ship had twelve operating rooms and four radiology

rooms. The core medical staff consisted of professionals from major Navy medical centers augmented by reservists. Comfort drew heavily from the Navy’s flagship hospital, the National Naval Medical Center in Bethesda, Maryland. Both

ships were essentially floating general hospitals, that is, fourth-echelon facilities,

where definitive care could be provided if the evacuation policy was long

enough.60

Although superbly equipped and staffed, the capability of the hospital ships

to receive mass casualties, unless tied up alongside piers in Saudi Arabia or

Bahrain, was problematic. Despite extensive experiments, attempts to embark

patients from various types of surface craft to the ships while the vessels cruised

offshore were essentially unsuccessful. The Navy found that patients could not be

brought aboard at sea by any means other than helicopter.61 Given the unique medical capabilities of the two hospital ships, strict adherence to Navy–Marine Corps

doctrine regarding opportune helicopter medevac obviously risked wasting some

of CENTCOM’s potentially most valuable medical support because the tactical

situation might dictate using the Navy and Marine Corps helicopters for operational missions. Consequently, doctrine was adjusted to need, and a squadron of

Army UH–60 Blackhawk helicopters was assigned to assist with medevac support

for these vessels. Because the Navy required that helicopter pilots be certified to

land on the hospital ships, a program to certify Army as well as marine helicopter

pilots was undertaken during the relative quiet of Desert Shield.62

Uncertainties regarding the availability of Marine Corps medevac assets also

affected Navy third-echelon MTFs deployed to support the marines. Fleet

Hospital 15 was established at al-Jubayl in early September at the request of Gen.

Walter Boomer, commander of CENTCOM’s marine forces, rather than on

Bahrain as originally planned. The general wanted this 500-bed, well-equipped

and well-staffed, third-echelon facility to be closer to his troops if they were to

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battle in Kuwait. Its twin, Fleet Hospital 5, located some five miles away, was also

dedicated to support the marines.63 As he acknowledged later, Boomer chose alJubayl in the erroneous belief that, as in Vietnam, medevac accomplished by

opportune helicopter lift would prove adequate to move marine casualties to these

facilities.64 Apparently less sanguine than the general about the adequacy of

Navy–Marine Corps doctrine in the event of large-scale casualties, and in spite of

the marines actually reserving eight CH–46s for medevac, the hospital itself

apparently requested help from the Army, which eventually assigned eight medevac Blackhawks to the hospitals in another example of out-of-doctrine cooperation.65 According to CENTCOM Deputy Surgeon Col. Benjamin Knisely, the

absence of adequate marine medevac capability caused his office to plan to use

C–130s as the primary means of evacuating casualties to the Navy fleet hospitals,

once the ground war commenced.66

The difficulties with Navy–Marine Corps doctrine regarding fleet hospitals

were further demonstrated when the ground war began. Both fleet hospitals were

within the unrefueled range of Blackhawks, but because the hospitals were

approximately 120 miles from Kuwait, helicopter evacuation to them was effectively precluded because the time it would have taken to transport a casualty by

helicopter from the battalion aid station or clearing and collecting company to the

hospital ship would have adversely affected patient outcome. As foreseen by the

CENTCOM surgeon’s office, when the ground war actually began, patients were

brought to rear-area airfields near the fleet hospitals by Air Force fixed-wing

transports, although not always in as timely a fashion as medically desirable,

before they were moved to the fleet hospitals by helicopter.67

Aside from the restriction that helicopters were the only access to the Navy

hospital ships, other questions regarding the utility of the hospital ships arose

because of the problem that helicopter range limitations posed for medevac in certain parts of the AOR. Assuming that helicopters had been available for the medevac of wounded marines in accordance with Navy–Marine Corps doctrine and

that they were available in sufficient numbers, their use to transport casualties to

the hospital ships from the second-echelon MTFs supporting the combat units

would have required that the hospital ships be brought farther into the Persian

Gulf, closer to the forward areas of the combat zone, where they might face some

risk in spite of their Geneva Convention status.

The Comfort did, in fact, move north of Al Khafji during the marine assault

in February and was attacked by Exocet missiles, even though it and the Mercy

were marked in accordance with and formally protected under the Geneva

Convention.68 In this location, the Comfort also encountered floating mines and,

as the Exocet attack demonstrated, was subject and vulnerable to attack, even possible seizure, by a clearly unprincipled enemy.69 Here, the Air Force–directed

TAES could provide the means to fill the range and provide security. As was done

for the fleet hospitals during the ground combat phase, C–130s could have moved

patients to rear airfields near the coast, where helicopters could transport them to

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the Comfort and Mercy while the ships remained at safer distances.70 In any event,

the Comfort’s admirable willingness to accept a calculated risk during the actual

marine assault on Iraqi troops in Kuwait was moot because the marine’s advance

took them rapidly out of helicopter range, and neither hospital ship received

marine combat casualties.71

Development of the Aeromedical Evacuation System

Although deployment of Army hospitals to support the growing ground forces

allocated to CENTCOM may have lagged behind deployment of the forces themselves, plans and activities to develop an aeromedical evacuation system capable of

supporting the estimated need were proceeding well. Instead of a war for the defense

of Saudi Arabia that Brannon had been told to expect within two weeks as he

deployed to the AOR, the many months of Desert Shield saw the CENTCOM mission change from deter and defend, as enunciated by the CENTCOM surgeon, to

one of offensive action to expel the Iraqis from Kuwait. The decision in late October

to more than double the size of the U.S. force, though quantitative, had qualitative

implications for aeromedical evacuation as well, and it affected issues such as command, control, and communications. Even more important to the development of

the system was the fact that so little of the previous planning for the aeromedical

evacuation of patients during a contingency actually applied to the current situation.

What Desert Shield/Desert Storm became for aeromedical evacuation in the USAF

was virtually a laboratory for evaluating and elaborating—currently called reengineering—the existing system to make it more capable of performing its increasingly important function in the new joint world and in the kinds of contingencies that

the United States would face in the post–Cold War world.72

The initial aeromedical evacuation system that elements of Brannon’s 1st AMES

established in mid-August consisted of the AECC, which was located together with

COMALF’s ALCC at Riyadh; two MASFs deployed at Riyadh and Dhahran; and

two AELTs for stationing with second- or third-echelon Army medical units. A third

ANG-manned AELT deployed to Incirlik, Turkey, to facilitate communications

between the aeromedical evacuation elements in Saudi Arabia and an AECE established by ANG personnel at Rhein-Main AB in Germany.73 The intra- and intertheater aeromedical evacuation flights consisted of twenty-four tactical aeromedical

evacuation crews from the ANG units initially polled; twenty were strategic crews

from the 69th and 72d AMESs at McGuire AFB; four were strategic aeromedical

evacuation crews from the 2d AMES, the active duty aeromedical evacuation

squadron based at Rhein-Main AB. The TAES attained initial operational capability

on August 13, and the first aeromedical evacuation mission flew that night.74

Once the initial estimates of casualties from operations against the Iraqis

were provided to Brannon and his AECC staff by the CENTCOM surgeon’s

office, they calculated the requirements for an aeromedical evacuation system

capable of supporting a force of some 200,000, the size General Schwarzkopf’s

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force was originally scheduled to become. In late August, these calculations yielded an increase in required personnel to 432 assigned in two AECEs, seven AELTs,

five MASFs, and twenty-four strategic aeromedical evacuation crews. Included in

this total were the unchanged requirements for one AECC and twenty-four tactical aeromedical evacuation crews.75 When Washington decided to reinforce

CENTCOM with the VII Corps from Europe and additional units from the United

States, revised casualty estimates were generated. After MAC Commander Gen.

H. T. Johnson refused a request from the theater to deploy the MAC’s C–9s

assigned to USEUCOM, it became clear that the aeromedical evacuation system

supporting CENTCOM would be operated primarily with retrograde airlift in

accord with Air Force doctrine.76

In mid-December the number of personnel with the necessary equipment

needed to provide the required aeromedical evacuation capability was recalculated on the basis of higher casualty estimates, and substantially increased. The new

requirements totaled 1,400 personnel, 92 percent of whom were drawn from the

ARC. With their equipment, they provided one AECC, five AECEs, twenty-two

AELTs, sixteen MASFs (four with personnel only), ninety-nine tactical crews, and

fifty strategic crews. Additionally, 109 more strategic crews also drawn from activated ANG and AFRES units were assigned to Brannon’s organization but were

staged in Germany under the operational control of the USEUCOM AECC.77

All these personnel were assigned to the new 1611th AMES (Provisional), a

unit created in early November 1990 under Brannon’s command as part of a new

provisional MAC unit, the 1610th Airlift Division (Provisional). Commanded by

the COMALF, the 1610th was intended to provide a single organizational structure for administrative and disciplinary purposes within which to fold the mixture

of active duty, AFRES, and ANG personnel. Under MAC operational control, this

single organization would provide airlift services including aeromedical evacuation for CENTCOM in the AOR.78

Well before the planned increases of December, Brannon’s organization had

begun to evolve in ways that mirrored the complexity of the requirements that

Desert Shield had imposed on the personnel and equipment that MAC had dispatched to Saudi Arabia. While the UN Security Council sought to reverse Iraq’s

occupation of Kuwait through diplomacy, peace, or at least the absence of conflict, reigned in the AOR. Regardless that U.S. military personnel now living in

the AOR were awaiting a decision to go to war, the aeromedical evacuation system had to function in an essentially peacetime mode, a fact that affected some

Army second-echelon medical facilities.

The new (after mid-October) COMALF, Brig. Gen. Edwin Tenoso, and

Colonel Brannon had to establish a theater aeromedical evacuation system that

during Desert Shield would function like the domestic aeromedical evacuation

system in the ZI, but its ultimate purpose was to support combat operations by

providing tactical aeromedical evacuation capability within the AOR as well as

strategic evacuation from the AOR to the COMZ. During this period, deployed

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MTFs had to treat various illnesses, numerous sports-related injuries, and victims

of motor vehicle accidents, all the while preparing for combat.79 If these patients,

categorized as Disease/Nonbattle Injuries (DNBI), could not return to duty within the fifteen-day theater evacuation policy, they had to be processed through the

aeromedical evacuation system and be aeromedically evacuated via C–141s to

Europe, the COMZ.80

Because U.S. forces, particularly Air Force squadrons, were dispersed widely across the Arabian peninsula, beginning in November 1990 C–130 Samaritan

missions provided intratheater patient transport to designated bases for evacuation

to Germany. These C–130 missions were conducted on a scheduled basis among

the principal aerial ports of entry—Dhahran and Riyadh—and among a network

of airfields serving U.S. medical facilities in Saudi Arabia, Bahrain, Oman, and

the United Arab Emirates (UAE).81

The C–130s operated from six initial bed-down sites, five of which were

located outside Saudi Arabia in Oman and the UAE. They flew the Samaritan

channels on a dedicated-mission basis and not as aircraft dedicated exclusively to

aeromedical evacuation. The C–130 bed-down sites were at Bateen, Al Ain, and

Sharjah in the UAE; Seeb, Mashirah, and Thumrait in Oman; and Al Kharj near

Riyadh, Saudi Arabia. Some C–130 units, including a detachment from South

Korea, moved to more forward bases in Saudi Arabia in January 1991 to ferry

troops west in preparation for the flanking attack, the left hook.82

Each aircraft normally carried all the equipment necessary to reconfigure it for

aeromedical evacuation, but the primary role of the C–130s was to move supplies,

equipment, and personnel throughout the AOR. After the air war began, C–130s

performed the critical task of ferrying troops of the 18th Airborne Corps to the marshaling points from which the invasion of Iraq was launched. Samaritan missions

continued throughout Desert Storm, evacuating casualties as well as DNBI patients.

By the time the coalition forces began combat, the tactical and strategic

aeromedical evacuation systems intersected at five strategic hubs: King Khalid

Military City and the International Airports (IAPs) at al-Jubayl, King Fahd, King

Khalid, and Muharraq.83 As a measure of the activity of this peacetime aeromedical evacuation system, during Desert Shield, from August 12, 1990, to January

16, 1991, the theater aeromedical evacuation system carried 551 litter and 1,585

ambulatory patients intratheater, and 1,194 litter and 2,071 ambulatory patients

intertheater.84

The theater aeromedical evacuation system that General Tenoso and Colonel

Brannon established functioned well in spite of the fact they had no directly relevant model upon which to shape the system. Vietnam was more than twenty years

in the past and had been fought with a different kind of force in quite different

geographic and logistic circumstances, which General Boomer acknowledges he

was forced to realize after the fact. The never-fought but intensively planned- and

trained-for NATO–Warsaw Pact war had involved a much different scenario and

infrastructure than the one the planners now confronted.

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Perhaps the major problem in the AOR from the point of view of not just the

aeromedical evacuation system but the entire medical support structure for

Schwarzkopf’s forces was the thin communications infrastructure.85

Compounding the problem of uncertain communications, for which technical

solutions could offer at least some help, other factors directly affected aeromedical evacuation but offered few solutions. Those responsible for the aeromedical

evacuation system, General Tenoso and Colonel Brannon, had to deal with the

tacit personnel ceiling for U.S. forces, the complex nature of the aeromedical

requirements posed by CENTCOM’s offensive planning, and the sheer size of the

aeromedical evacuation forces that actually deployed, as well as the various

sources from which they came.

Although ultimately untested in its ability to respond successfully to the predicted levels of casualties against which it was sized, the theater aeromedical

evacuation system that Brannon and Tenoso created functioned well and reflected a thoughtful, creative approach to fulfilling the system’s requirements. Their

success demanded flexibility and a willingness to transcend doctrine and make ad

hoc decisions within the AOR, MAC headquarters, TAC, and USEUCOM, all of

which were constantly in contact during the crisis.

Perhaps symbolic of the nature of obstacles to be overcome was the fact that

neither Tenoso, the COMALF, nor Col. Leonard Randolph, the CENTAF surgeon,

initially understood what their respective responsibilities were regarding the

aeromedical evacuation system. General Tenoso was surprised upon arrival in

Riyadh to learn that, as COMALF, theater aeromedical evacuation was under his

command, and Randolph initially believed that the AECC and the aeromedical

evacuation system were responsible to him as the CENTAF surgeon.86 Randolph’s

general responsibility for the medical support of deployed Air Force personnel

and his specific responsibility for the Air Force’s ten ATHs in the AOR suggested

that the Air Force–operated system should fall under his control. In spite of the

somewhat complex command relationships that existed in the AOR, all available

evidence points to excellent working relationships among Tenoso, Brannon,

Randolph, and the CENTCOM surgeon, Colonel Belihar, and his deputy, Colonel

Knisely, and their senior subordinates.87

Many problems remained in building an aeromedical evacuation system

capable of effectively supporting the CENTCOM forces. Most arose from the

expanded medical requirements generated by the scope of the projected combat

and casualty estimates. The small management elements deploying with the

strategic crews and the personnel of the AECC were no longer adequate, and the

UTCs for the tactical flight crews contained no management elements.

Additionally, the number of personnel authorized and assigned to the AECC,

AELTs, MASFs, and certain other elements of the system were found to be too

few to provide this function on a continuous basis as operations required. Certain

technical support in logistics and maintenance for equipment, such as generators

upon which the deployed aeromedical evacuation teams depended to provide

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power for their Pacer Bounce HF radios, were simply unavailable in the austere

environment of the AOR.

To help solve such personnel-related problems, Brannon initiated requests

that ultimately resulted in MAC’s generation of new UTCs to provide the capability that the ARC aeromedical evacuation units required.88 In addition to the

need for more personnel and specific capabilities, effective command and control

of the widely dispersed, and in many cases augmented, aeromedical evacuation

elements required adjustments to existing doctrine and procedures. In Desert

Shield/Desert Storm, MAC had deployed for the first time AECEs to manage

strategic aeromedical evacuation operations at each of the five strategic hubs.

Later, as the concept of the strategic hub evolved, the AECE functions were

expanded to include operational control of all medical and aeromedical elements,

both tactical and strategic, at each hub where there was direct involvement in

aeromedical evacuation.

The officer-in-charge (OIC) of each hub was designated Director, Aeromedical

Operations and made responsible ultimately to the AECC.89 At any given strategic

hub, the director exercised operational control over the AECE, MASF, aeromedical

evacuation crew members (AECMs), aeromedical staging facility, and whatever

type of patient reception element was present to receive patients and provide triage.

Organizations over which he had control thus included an Army clearing company

or platoon, a Navy or Marine Corps collecting and clearing company, or any similar element from any service component—Army, Navy, or Marine Corps.90 The

inclusion of elements not normally under AECC authority, such as aeromedical

staging facilities and the patient-receiving elements from other services, suggests

the high degree of cooperation and substantial amount of trust accorded Brannon

and the aeromedical system that he had largely been responsible for creating.91

Brannon also requested augmentation of the AECC, and the arrival of augmenting personnel in mid-September allowed him to expand the capabilities of

the AECC beyond its primary function of daily operations. The new functions,

assumed as the need arose, permitted the 1611th to operate largely as an essentially autonomous unit under the air division that Tenoso commanded. These functions included a contingency planning cell, a training and standardization section,

a flight clinical coordinator/aircrew manager section, a medical logistics section,

and an orderly room.92

The planning cell was given the mission of preparing the AECC to support

its wartime requirements. Its tasks included discussing requirements of the unitlevel medical planners of the different service components for aeromedical evacuation support, developing intratheater aeromedical evacuation flow proposals to

support the casualty estimates provided by the CENTCOM command surgeon,

and coordinating C–130 aeromedical evacuation mission requirements based on

flow proposals with the ALCC.

The training and standardization section was established only in early

November after the OICs at various medical-crew staging locations ascertained

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that some AECMs were not fully prepared to perform their duties, a situation

largely rooted in the diverse ARC units from which the crew members were

drawn. Some AECMs had never flown actual patient missions, many were unfamiliar with certain types of equipment or with the aircraft being flown, and all

flew missions according to the standards of their home unit. In many cases, these

standards included configuring an aircraft for patient evacuation according to the

preference of the MCD, a practice that tended to create confusion when crews

from different ARC units were mixed or when they relieved other crews to continue a mission on an already configured aircraft. Programs created to remedy

these situations included cross-training strategic and tactical aeromedical evacuation crews so they could function efficiently on either a C–141 or a C–130.93

Orderly room functions were the traditional ones—administrative support for

routine matters such as pay, promotion, and mail for personnel assigned to the

aeromedical evacuation system. Performed as additional duties by the AECC and

AECEs for the first five months, the 300 percent increase in personnel assigned

to the squadron just before the onset of hostilities made this extra task impossible

to sustain. Consequently, Brannon requested a contingent to establish a dedicated

orderly room for the 1611th, with a Medical Service Corps officer as the headquarters squadron section commander, a first sergeant, and three medical administrative specialists assisted by eight to ten temporary personnel.

More directly related to the operation of the aeromedical evacuation system

as a whole was the medical logistics section. As in USEUCOM, the Army was

charged as the single integrated logistic agency for CENTCOM forces. The establishment of the main logistics unit in the AOR, the Medical Support Optical and

Maintenance (MEDSOM), as Army medical supply centers were called, proved

to be extremely slow. Only at the start of the air war in January was it beginning

to provide most theater needs well, according to the then-CENTAF surgeon.94

Whereas Brannon created a formal chief of logistics position reporting directly to him only in February, medical logistics support had been a major problem

for both Army and Air Force medical units deployed to the AOR since August.

When the commander of the 44th Medical Brigade arrived with an advance party

on August 11, he found the prepositioned supplies on Bahrain totally lacking in

some important medicines. To order stocks of the medical supplies, he and his

staff spent literally hours, at huge expense, on the telephone to the Army Materiel

Agency at Fort Dietrick, Maryland, passing nomenclature and federal supply catalogue numbers to obtain the requested items.95

The only aeromedical supplies initially available in the AOR were those

brought by the MASFs and the reserve aircrews from several ARC units.96 The situation gradually improved, in part because of an unconscious replay of the way

the AAF Medical Service provided medical supplies to their flying units overseas

during World War II when the Army surgeon general’s staff was having trouble

doing so. Until stopped by the CENTAF surgeon, ATHs drew upon CONUS

stocks through requests to their parent bases for needed items, which were then

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shipped by air directly to the AOR, bypassing normal supply channels that, in fact,

had not yet been established. The aeromedical evacuation supply situation also

improved because Brannon directed that all newly assigned aeromedical evacuation personnel come fully equipped.

Medical supplies were also purchased locally, but the major source came

through the use by the CENTAF surgeon’s office of agents within USEUCOM

who requisitioned medical supplies directly from the U.S. Army Medical Support

Center, Europe, at Pirmasens, Germany. This method provided a relatively short

turnaround time for requests, sometimes only a week, depending on the availability of airlift from Germany to the AOR.97 CENTAF also drew upon the generosity of the USAFE surgeon for special equipment, although this was done sparingly for the same reason that requisitions to the CONUS units had ultimately been

stopped: CONUS units and USAFE both needed the same equipment. As the

beginning of the air war approached and in anticipation that its air bases would

probably be struck soon after hostilities commenced, CENTAF gradually built up

its own MEDSOM, a stockpile of medical supplies at Thumrait, one of the C–130

bed-down bases.98

The difficulty of obtaining medical supplies notwithstanding, Brannon’s staff

gradually established a workable logistics system, drawing upon the aforementioned sources to provide medical materiel that various elements of the aeromedical evacuation system needed to function. Flight nurse Capt. Jill Von Rothe is a

prime example of the versatility demonstrated by aeromedical evacuation personnel until adequate staffing was finally obtained on the eve of Desert Storm. Aided

by two medical logistics technicians and several other flight nurses, Captain Von

Rothe created an aeromedical evacuation logistics system that assembled and

shipped weekly an average of eight pallets of medical supplies to aeromedical

evacuation elements throughout the AOR, collected equipment packages with

which to outfit ten MASFs prior to their deployment, and had the capability to

respond to major new requirements as they appeared. As a volunteer, Von Rothe

built this aeromedical evacuation logistics system largely without supervision.

These flight nurses taught themselves how to manage medical logistics.

After receiving the substantially increased casualty estimates in early

December, the AECC directed that thirty-day resupply packages be prepared for

the AECEs, C–130 bed-down sites, and MASFs. The logistics section was able to

build approximately fifty pallets and deploy forty-two to their required destinations within eight weeks. All the required pallets were completed and delivered

prior to the start of the air war.99

Elements of the aeromedical evacuation system to be supplied were widely

dispersed, but they were knitted together by the sometimes uncertain HF radios or

occasionally by the varied and limited (and heavily used) other communications

means available at the different sites in the AOR where U.S. forces were located.

For example, before the ground assault, twelve MASFs were deployed to forward

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gical support companies, and several were designated to follow the advancing

troops into Iraq and Kuwait. Nineteen AELTs deployed primarily in support of the

combat forces, and some were located at fixed Navy and Army medical facilities

in Saudi Arabia and Bahrain.

To ensure aeromedical evacuation system responsiveness to requirements, by

the beginning of the air war tactical aeromedical evacuation crews were stationed

at the two tactical airlift bed-down bases and at each of the five strategic hubs

where patients were to be staged for evacuation to Europe. For retrograde evacuation missions to Europe, prepositioned strategic crews obviated the need for

C–141s to bring in crew members on routine airlift missions to the AOR from

Germany to reconfigure the aircraft and provide in-flight medical care in the

return flight. The tactical AECMs not only provided an immediately available

capability to reconfigure C–130s that had terminated other operational missions

at the strategic hubs, they also provided a source from which to draw flight crews

so the aircraft could be dispatched with minimal delay on intratheater evacuation

missions. As the time for the ground campaign neared, the tactical crews were also

stationed at MASFs for retrograde aeromedical evacuation missions, further

increasing the responsiveness of the theater aeromedical evacuation system. To

assist the widely distributed evacuation elements in communicating with Army

units, the CENTCOM surgeon’s office purchased a large number of FM radios

from commercial sources and distributed them to the Air Force MASFs and

AELTs.100

During Desert Shield, the medical regulation of patients from the AOR to

USEUCOM was conducted by the Joint Medical Regulation Office (JMRO) in

Riyadh, which was in direct contact with the USEUCOM JMRO. The USEUCOM JMRO routinely used the DMRIS in its peacetime mode, which required

the identification of the patient and the patient’s medical condition.This, in addition to the regulating information, required filling in some twenty-odd data fields.

It was a lengthy process that raised questions about the realism of expecting such

a system to work if CENTCOM’s medical support facilities were inundated with

casualties.101

The Role of Flight Surgeons in the

Aeromedical Evacuation System

Aeromedical evacuation operations in the Persian Gulf War were to further

advance the arguments of those in the Air Force Medical Service who believed

that the policy restricting evacuation by air to stable patients should change. These

physicians wanted MAC to accept stabilized patients for movement, with the

implicit corollary that Air Force medical attendants with critical-care skills would

accompany such patients to provide medical intervention if necessary while in

flight. Not yet accepted as doctrine within the Air Force or MAC, this concept also

had its adherents in the Army. In spite of continuing the formal adherence to a

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return-to-duty concept, other ideas had begun to gain ground in the Army Medical

Department. “Return to duty” required relatively large and sophisticated MTFs

located in the combat zone where patients could be held pending return to their

units in the field. Some senior physicians in the medical department had begun to

look seriously at the concept of clearing the battlefield, which implied keeping

fewer casualties forward.102

The Army’s positive experience with aeromedical evacuation during

Operation Just Cause had also impressed some members of its medical department, although the Army surgeon general later expressed concern that the successful evacuation of unstable patients during the Panama operation might be

interpreted by Congress as an indication that funding for the Army’s forwardbased medical units should be reduced. More favorably inclined toward the evacuation of such green patients was the commander of the 44th Medical Brigade,

Col. Jerome Foust, with whom Brannon had worked at Howard AFB during Just

Cause and who had deployed with him to Saudi Arabia. Foust expected and would

have welcomed the same degree of responsiveness, as he termed it, in the

aeromedical evacuation system in the CENTCOM AOR that the Air Force established during the Panama operation.103

The key to the successful aeromedical evacuations from Howard during Just

Cause was the availability of rapid initial surgical intervention—surgery within

the golden hour, as it were—to stabilize the patient and enable him or her to

endure the flight to San Antonio without suffering further harm. Ideally, though

actually done on only two of the Howard evacuation missions, placing a physician onboard as a precaution against a possible decline in the patient’s condition

while airborne was a logical corollary to the decision to move a patient who was

not yet fully stable clinically.104 Within this context, the perhaps unwitting agents

in helping build a new consensus within the Air Force medical community regarding the transportation of unstable patients were the ten flight surgeons who had

arrived in the AOR early in Desert Shield and whom Brannon had neither requested nor particularly wanted.

With no specified function to fulfill in the aeromedical evacuation system, the

flight surgeons tended to languish in Riyadh. Chosen quickly and somewhat arbitrarily in a few cases, most among this first group had only limited experience in

aeromedical operations. Consequently, their collective utility was limited

although their individual contributions varied and, according to observers,

depended to a large degree on individual initiative and drive. Throughout 1990,

operating from Riyadh, these ten flight surgeons were used primarily as flight

attendants and periodically visited tactical units, but they were not assigned to any

specific organization, nor were they integrated fully into the system.105

The arrival in early January of MAC Deputy Command Surgeon Col. Earl

Mabry provided the catalyst to create a more meaningful role for flight surgeons

during Desert Storm and ultimately provided grist for those favoring a change in

the Air Force policy on transporting only stable patients. Mabry, a flight surgeon

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A History of Aeromedical Evacuation in the U.S. Air Force
himself, was sent to the AOR in an advisory role by MAC Commander General

Johnson to provide a physician’s perspective to the CENTCOM surgeon on the

operation of the aeromedical evacuation system. Responsible for the system

established by Brannon, General Johnson wanted to ensure that this pioneering

effort was effective in supporting CENTCOM requirements and that the operational concept underlying the system worked.106

Brannon apparently developed a CONOPS for utilizing the flight surgeons,

but experience with aeromedical evacuation was so scarce as to make it impracticable to attempt to implement his concept immediately. In any case, more pressing concerns—manning, organization, and medical supply—demanded his attention. Eight of the ten flight surgeons were rotated from Riyadh among the five

C–130 bed-down sites to better acquaint them with the evacuation system and the

medical flight crews assigned. Of the two remaining flight surgeons, one was

assigned in Riyadh to the CENTAF surgeon’s office and the other was assigned to

the JMRO, which was equipped with the DMRIS terminal and collocated with the

AECC.107

Finding ways to utilize flight surgeons in aeromedical evacuation was not

part of the charter that General Johnson provided Colonel Mabry with when he

departed MAC headquarters. In fact, Mabry was not even aware of the flight surgeons’ presence in the theater until after his January arrival in Riyadh.108 As he surveyed the evacuation system and had discussions with the physicians at the

numerous Army MTFs that were rapidly being established in anticipation of the

ground war, Mabry became convinced that flight surgeons, twelve more of whom

arrived shortly after the air war began, could fulfill several important functions.

At the MTFs operated by the other service components, he discovered a considerable lack of understanding about the evacuation process, such as how the system functioned, what were the procedures for requesting evacuation by air, how

patients were to be prepared for evacuation aeromedically, and which patients

were candidates for aeromedical evacuation. Moreover, this lack of understanding

was coupled with a tendency to designate patients for this type of evacuation perhaps too readily, an understandable tendency given the imminence of the ground

war and the large numbers of casualties that Army physicians had been led to

expect.109

Perhaps more important, Mabry learned from these conversations that the

MAC policy that required an MTF delivering an unstable patient for evacuation

to provide an accompanying medical attendant and any necessary equipment such

as a ventilator or cardiac monitor was untenable in the AOR. Given the expected

level of casualties, an Army or Navy hospital that adhered to such a policy would

soon be denuded of its physicians and equipment, including the more prosaic but

vital litters on which patients were transported.110

This meant that the aeromedical evacuation system, particularly the intratheater segment, would almost certainly have to carry unstable patients who required

physicians trained in critical care and having some experience in aeromedical

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evacuations to assist the usual medical flight crew. These augmentees would have

to come from the Air Force, and Mabry realized that flight surgeons provided a

cadre that could be tapped for this purpose. The original ten flight surgeons

received refresher ATLS training at their quarters in Riyadh and were then dispatched to aeromedical evacuation units in the field. They developed a uniform

trauma management kit, drew upon local supply sources to assemble their kits,

and had begun flying aeromedical evacuation missions on a regular basis by

January 15. Twelve additional flight surgeons arrived in January, and Mabry

solicited the assignment of more with critical-care backgrounds to perform the

newly specified functions of aeromedical evacuation flight surgeons (AE/FS).

Eventually Mabry was able to assemble a group of thirty-two flight surgeons in

direct support of aeromedical evacuation. As more flight surgeons arrived, they

were assigned either as tactical AE/FS at one of the six C–130 bed-down sites or

as strategic AE/FS at one of the five strategic hubs from which C–141 flights

evacuated patients to England and Germany.111

To facilitate the smooth functioning of the system, the AE/FS in the field

established direct liaison with local MTFs where, among other things, they presented briefings on the wartime function of the system, its capabilities and limitations, and its requirements for preparing patients. They also conducted in-patient

consultations to address special transportation problems with the local medical

staffs.112 Several provided trauma training to aeromedical crews who, because they

were predominantly from the ARC, had limited experience in transporting seriously injured patients. The AE/FS were also assigned to MASFs, and they served

as squadron medical elements for the aeromedical evacuation units at the beddown sites and strategic hubs because, alone among all Air Force flying organizations, the aeromedical evacuation squadrons had no assigned flight surgeons.

The flight surgeons flew all missions, including scheduled Samaritan missions,

and, although they deferred to nurses who were MCDs on flights not requiring

their skills, they performed a number of in-flight interventions when it became

necessary.113

Mabry and his flight surgeons were also able to secure outside help. They

recruited sixty additional physicians from local MTFs to act as aeromedical evacuation opportune physicians, forty of whom volunteered to support the TAES and

twenty of whom volunteered to support the strategic system. Most of the volunteers were Air Force flight surgeons from other Air Force organizations, and some

served as squadron medical elements with U.S. flying units at the same base or

were assigned to aeromedical staging facilities. A few were non–flight surgeons

from Air Force ATHs and Army evacuation hospitals.114

These volunteer physicians were used most commonly to support aeromedical evacuation missions with a large number of critical-care patients. None were

used without coordination with their unit commanders, who tended to favor this

tactical system because physicians could be returned to their station on the same

day, whereas strategic missions to Europe caused their return to be delayed by 48

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The Persian Gulf War: Test of the Total Force

to 72 hours. These additional resources permitted 1,200 patients to be transported

through King Khalid Military City during Desert Storm, with physicians available

on the evacuation flights.115

Paralleling this modification of Air Force medical doctrine and complementing it to some degree were similar informal changes in the Army tactical medical

doctrine dictated by the situation in the Gulf. The DEPMEDS hospitals the Army

dispatched to the AOR were designed to be mobile, but they proved to be much

less so because of the nature of the theater and the character of the combat envisioned. In Vietnam, Army mobile and relocatable hospitals became fixed installations early on. In the Persian Gulf War, DEPMEDS took a great deal of time to

erect and disassemble and they required not only a large number of aircraft to

deploy but also the ground vehicles to transport them.116 It became evident quite

early in Desert Shield that there was simply no way that, as constituted, the

DEPMEDS could be moved quickly enough (or, depending on the terrain to be

crossed, perhaps moved at all) to provide medical support to rapidly moving

armored forces in desert warfare.117 The solution was to lighten MASH units,

including their FASTs, and create forward surgical elements (FSEs) for even

greater mobility. The 5th MASH was the first to develop FSEs by extracting small

teams of surgeons and other trauma specialists from the MASH’s surgical staff,

equipping them with minimal essential medical equipment, providing transportation to make them extremely mobile, and deploying them forward, close to the

areas of combat. There they could provide the initial time-sensitive surgical intervention on patients, and they were mobile enough to keep up with the armored

formations.118 After casualties had received resuscitative surgery at these FSEs,

they could be moved as “green” patients on C–130s to hospitals in the rear for further care or aeromedical evacuation to the COMZ by C–141s. The new availability of en route critical care in both the tactical and the strategic aeromedical evacuation systems complemented this FSE concept precisely.

USEUCOM’s Role in CENTCOM’s

Medical Support Structure

With the initial deployment of forces to the Persian Gulf, USEUCOM was

suddenly placed in the position of having to fulfill its designated role as

CENTCOM’s COMZ. As in the AOR, a great deal of improvisation would be

required because little detailed planning had been done for USEUCOM to assume

such a role in a Middle Eastern conflict. Its mission for decades was to support

Allied Command, Europe, the military arm of the NATO alliance. In terms of the

unified command plan that governs relationships among U.S. theater commanders,

CINCEUR would have been viewed as the likely supported CINC in the most

probable conflict the United States would have faced during the NATO–Warsaw

Pact period, subsequent to the Vietnam War. Instead, CINCEUR was suddenly cast

in the role of a supporting CINC, as were the other U.S. theater CINCs.119
Fortuitously, a functioning vehicle for medical coordination was already present in USEUCOM. It was the Medical Coordinating Committee (UMCC) composed of the USEUCOM surgeon, Maj. Gen. Alexander “Rusty” Sloan, USAF,

and the command surgeons of USEUCOM’s component commands, including

USAFE’s Brig. Gen. Charles “Chip” Roadman. The UMCC had been meeting

quarterly prior to the Persian Gulf crisis, and within a week of the initial U.S.

deployments it initiated a series of monthly meetings that served as the principal

vehicle for deciding and executing medical policy during Desert Shield/Desert

Storm.120

The UMCC used initial planning parameters of an assumed 350,000 U.S. personnel at risk in the Gulf region, an evacuation policy of seven days in the AOR

and fifteen days for USEUCOM, and all patient evacuations flowing through

USEUCOM rather than being transported directly from the AOR to the ZI.

Modeling based on these parameters at both USEUCOM and the Pentagon using

the Joint Staff’s medical planning model led the UMCC to adopt General Sloan’s

recommendation that USEUCOM plan to provide 5,500 beds.121 The issue of how

to fill such a large requirement quickly focused the committee’s attention on the

Air Force’s contingency hospital system.

Developed to require essentially only staffing to become quickly operational

in the event of a NATO–Warsaw Pact conflict, USAFE’s contingency hospitals

provided the potential to substantially increase medical treatment capability in the

European theater.122 Consequently, USAFE Commander General Oaks directed in

September that preparatory steps be taken toward activating the contingency system to provide beds for casualties from the AOR. USAFE was tasked to provide

3,750 of the planned 5,500 beds. To fulfill this requirement, four Air Force contingency hospitals were to be opened: one at Zweibrucken, Germany, and three in

the United Kingdom at RAF Little Rissington, RAF Nocton Hall, and RAF

Bicester. Additionally, the capacity of four regular Air Force hospitals was also to

be expanded. The four were at Wiesbaden, Germany; Torrejon, Spain; RAF

Lakenheath; and RAF Upper Heyford. These actions imposed on USAFE the

additional task of bringing out aeromedical staging facilities from storage and

assembling them at the reception airfields. Not until early December, roughly a

month after the VII Corps was ordered to the AOR from Europe, was the Air

Force contingency hospital system formally activated and personnel to staff them

deployed.123

The Danes offered another contingency hospital at Holstebro; they also

offered medical staff and airlift to move U.S. patients from Germany to Denmark

on a Danish aeromedical evacuation Boeing 737. Further, the Danish government

identified Danish families to host the relatives of U.S. casualties who became

patients at Holstebro.124 Other NATO partners of the United States were also

extremely supportive in the medical care area. According to the then-MAC commander, several of his C–141s landing in Luxembourg were not even allowed to

pay for refueling.125Germany reserved 1,000 beds for U.S. patients, primarily in

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A History of Aeromedical Evacuation in the U.S. Air Force
surgical wards in hospitals in Koblenz, Ulm, Hamburg, Giessen, and Munich.

Helicopters and ambulances sufficient to transport up to 1,000 wounded U.S. personnel per day from the airfields at Ramstein, Rhein-Main, and Nuremberg to

U.S. or German military hospitals were also marshaled. A total of 10,000 beds

were promised by allied nations if they became needed. USAFE also established

aeromedical staging facilities in which patients arriving by air could be received,

triaged, restabilized, and held until transported to MTFs.126

USAFE Command Surgeon General Roadman, through what he later called

stand-off oversight of the aeromedical evacuation system, sought to determine

early in the crisis just how ready the European segment of MAC’s worldwide

aeromedical evacuation system was to support a patient flow from CENTCOM.127

The issue was of far more than passing interest to Roadman because he was

responsible for administering the Air Force hospital system into which casualties

from the AOR would flow. The 2d AMES and the C–9A Nightingales of the 55th

Aeromedical Airlift Squadron based at Rhein-Main AB would be essential to distribute evacuees from the AOR to the various Army and Air Force MTFs distributed within Europe, or perhaps to evacuate patients from the AOR.128

The late activation of the contingency hospitals in Europe paralleled the late

deployment of Army third-echelon MTFs to the AOR, and for generally similar

reasons: the low priority given the airlift of medical capabilities and resupply. The

senior Air Force medical leadership was also concerned not to deploy capabilities

too early.129 What especially hampered the problem of planning and generating the

required medical capabilities was the fact that the information on which the projections were based—casualty estimates provided to USEUCOM—varied significantly over time, creating difficulty for the medical planners. General Roadman,

who was reassigned to MAC after the war, noted in 1992 that he had found these

changes particularly distracting. He related that at one point the medical planning

module used by the JCS to project casualty figures had provided different versions

almost simultaneously, one doubling the projection of the other.130

The final evacuation requirements that Tenoso and Brannon received as actual hostilities grew imminent—up to 2,500 per day from the AOR to the COMZ—

within a few days would have swamped the beds that USEUCOM had been

tasked to provide. The original evacuation policy for the COMZ established by

USEUCOM had been modified with CENTCOM’s agreement to increase to sixty

days until hostilities commenced, after which it would revert to fifteen days, but

the projected initial casualty rates would have made even this an unsustainable

policy. Strategic aeromedical evacuation of patients to the ZI after being stabilized

in COMZ MTFs could provide the means to clear beds sufficiently to cope with

large subsequent groups of patients. Complicating the issue was USAREUR

Commander Gen. Crosbie Saint’s concern to retain casualties from his VII Corps

in Europe, where their families were still largely located. Ultimately, the situation

resulted in a three-day flow-through policy, adopted originally as a temporary

expedient until the contingency hospital system became fully operational but

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The Persian Gulf War: Test of the Total Force
becoming policy for all patients evacuated from the AOR to USEUCOM once

hostilities began.131

This accorded well with the optimal medical treatment of potential evacuees

because it is generally accepted that the three- to five-day period immediately following initial resuscitative surgery is when patients can be transported with the

least chance of infection or medical complication.132 Transportation as quickly as

possible to definitive care in the United States, where greater medical capability

is available at MTFs, VA hospitals, and civilian medical centers, might be clinically beneficial, but it tended to contradict the return-to-duty philosophy underlying the medical support system that had been built to support CENTCOM.

CENTCOM’s acquiescence in this policy, realistic as it might have been, marked

perhaps the first overt step toward the 1998 evacuate-and-replace policy that

implies profound modification of the entire echelons-of-care concept.

Also realistic was the Air Force’s willingness to depart from the retrograde

airlift principle on which aeromedical evacuation had depended, with some

exceptions since the early 1930s, and accept the potential need for dedicated

strategic aeromedical evacuation missions. The need for dedicating missions to

aeromedical evacuation rather than relying on retrograde airlift became apparent

in December with dissemination of the final casualty-rate projections. The AOR

raised the issue in message traffic with MAC headquarters, and while the airlift

command temporized its view of the effect that removing C–141s from the airlift

of personnel and supplies to the combat zone would have on CENTCOM preparations for war, it indicated it was open to the idea.133 Informally, MAC agreed

that, when casualty rates had reached such a level that retrograde airlift aircraft

were unable to evacuate patients from the AOR quickly enough to free sufficient

beds to accept fresh casualties (traditionally, the Army Medical Department

sought to keep 40 percent of forward hospital beds unoccupied to provide surge

capability134), the airlift command would reconsider its adherence to retrograde

airlift for aeromedical evacuation. Dedicated aeromedical evacuation missions

were therefore injected into the CONOPS for aeromedical evacuation that the surgeon general’s staff was finalizing.135

Another resource would also be called upon, if necessary. The aeromedical

evacuation segment of the CRAF could be activated to supplement the strategic

aeromedical evacuation capability available in retrograde and dedicated missions.

Before the war, MAC had contracted for the AESS, and a number of commercial

airlines had committed themselves to support an aeromedical evacuation segment

in the third stage of the CRAF. Delivery of the AESS was not scheduled to begin

until July 1991, but heavy pressure from General Johnson compelled the contractor to advance the schedule. By mid-January, ten AESS were available and a decision to activate the aeromedical evacuation segment was being considered.136

The experience of USAFE Commander General Oaks also affected the

aeromedical evacuation system. During Operation Just Cause he had been the

senior Air Force officer in the San Antonio area with responsibility for the mili222

A History of Aeromedical Evacuation in the U.S. Air Force
tary medical facilities receiving the casualties of the Panama operation.

Remembering the problems encountered then, Oaks directed that family reception

centers be established at all the major civilian airfields to assist civilians arriving

from the United States in finding family members who had been evacuated from

the AOR to USAFE hospitals. Oaks also directed General Roadman in early

January to create a patient-tracking system that would be initiated when a casualty entered the aeromedical evacuation system.137

The Final Planning for Aeromedical Evacuation

Almost daily telephone conferences throughout December among the principal medical officers at TAC, MAC, USEUCOM, USAFE, CENTAF, and CENTCOM were part of the intensive efforts to provide the necessary medical support

for CENTCOM. MAC published a draft CONOPS for aeromedical evacuation on

December 15, 1990. Final planning for how the system was going to work was

realized at a two-day conference in the AOR where representatives from MAC,

the concerned commands, and agencies in Europe and the AOR met face-to-face.

Col. Carroll Bloomquist, MAC’s director of Readiness Planning, arrived at RheinMain in late December to talk with the 2d AMES staff. On successive days he

briefed General Roadman, General Oaks, and members of the USEUCOM staff,

including the European theater JMRO, on the aeromedical evacuation CONOPS.

Representatives from these European agencies accompanied Bloomquist to

Riyadh where the conference was held at CENTCOM headquarters.138

Many details were settled at this conference led by Colonel Belihar, but the

two major issues were hub-to-hub regulating and dedicated aeromedical evacuation missions, and agreements were reached in both cases. That a consensus transcended doctrine itself was perhaps the most important because the agreements

themselves were overcome by events: the quick end to the war and the low level

of casualties. Interestingly, the conferees agreed on tentative solutions for problems inherent in any large-scale operation conducted in the CENTCOM AOR

with the then-current state of doctrine and readiness of the aeromedical evacuation forces. The critical element in the situation was the fact that the duration of

Desert Shield had allowed these issues (and others in the structuring of medical

support for General Schwarzkopf’s forces) to be addressed without a cost in lives,

as might have been the case had the eventual conflict occurred earlier in the

buildup of U.S. forces.

The proposed solutions were grounded in the unique realities of the situation

that General Schwarzkopf faced and the collective experience of those involved

with aeromedical evacuation. Hub-to-hub regulating was an attempt to anticipate

and avoid the problems that evacuations on the scale predicted would have created for the medical regulators at the JMROs at Riyadh and Rhein-Main. DMRIS

terminals for automated medical regulating linked to the JMRO at Rhein-Main

had been deployed at Riyadh and Bahrain. The Army’s equivalent of DMRIS, the

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The Persian Gulf War: Test of the Total Force
Theater Army Military Medical Information System (TAMMIS) for regulating

Army patients in the AOR, had a design capability for an automated input to

DMRIS.139

This theoretically provided a comprehensive system for medical regulation

linking evacuation hospitals to the ASMRO at Scott AFB, which regulated

patients to MTFs in the ZI. Medical regulation during Desert Shield, in the measured but obviously strongly felt words of the commander of the 44th Medical

Brigade, had some very serious problems, not the least being that TAMMIS interfaced with DMRIS imperfectly.140 Even if the automated systems had been compatible, the contingency regulating system provided no way to track a patient.

When hostilities commenced (or preferably before, to allow the regulating officers to familiarize themselves with the changes), contingency regulating information transmitted to the USEUCOM JMRO from its counterpart at Riyadh would

consist only of the number of patients categorized by their wounds or illness. The

extended use of the peacetime regulating system during Desert Shield, with its

vast information requirements, prevented regulators from familiarizing themselves with the contingency system.141

Also described as a push system, the concept of hub-to-hub regulating originated with Medical Service Corps officers experienced in aeromedical evacuation

in MAC. Colonel Bloomquist’s observation of the aeromedical evacuation system

in Europe during five years in USEUCOM followed by three more on the SHAPE

staff convinced him that the European regulating system would be unable to handle the predicted flow of casualties. Brannon shared this conviction, not least

because of his intimate knowledge of the strength and weaknesses of the intratheater aeromedical evacuation system and its interfaces with the strategic aeromedical evacuation system, all of which were essentially his creation. He also

undoubtedly drew on his observations of JMRO capabilities, because it was collocated with the AECC.142

The concept of hub-to-hub regulating was relatively simple: patients evacuated from a particular strategic hub in the AOR would be transported by a mixture

of retrograde and dedicated aeromedical evacuation missions to a paired airfield

in Germany or the United Kingdom. From there, patients would be distributed to

appropriate hospitals after triage and processing through the aeromedical staging

facility. The paired hubs were King Khalid IAP at Riyadh with Rhein-Main AB,

Germany; King Khalid Military City, the MedBase America, with Ramstein AB,

Germany; King Fahd IAP near Dhahran with RAF Waddington, United Kingdon;

al-Jubayl IAP, farther north on the coast, with RAF Upper Heyford, United

Kingdom; and Muharraq IAP on Bahrain Island with RAF Upper Heyford.143

Depending on location and distance to be traveled, patient distribution would be

made by C–9s from Rhein-Main, by helicopter, or by ground ambulance. When

hostilities commenced later in January, it became painfully obvious that conferees

had carried away from the January aeromedical evacuation meeting a different

understanding about when this system was supposed to be instituted.144

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A History of Aeromedical Evacuation in the U.S. Air Force
A corollary issue decided at the January 4 meeting involved dedicated missions in which aircraft come under the Geneva Convention and cannot be used for

any other purpose. MAC agreed to allocate eleven such missions per day to the

strategic aeromedical evacuation of patients from the AOR to the European

COMZ. When the requirement for patient movement reached an agreed-upon

level, aircraft arriving at Rhein-Main would be reconfigured for aeromedical

evacuation to save time and be launched as necessary with medical flight crews

deployed to Europe to support such missions.145 The same approach was approved

by General Tenoso, the COMALF, who agreed to dedicate two squadrons of

C–130s for intratheater aeromedical evacuation at the point when retrograde airlift could no longer support the required patient movement in the AOR.146

The somewhat tenuous understanding of these agreements by the concerned

agencies was revealed fairly rapidly when Brannon, using one of the dedicated

missions allocated, sought to test the hub-to-hub system after the air war began.

MAC disapproved the diversion of airlift missions from CENTCOM’s operational priorities because airframes were in short supply and retrograde C–141s

were still capable of handling the then-existing patient airlift requirements.147

While these issues affecting the operation of the aeromedical evacuation system within the CENTCOM AOR and between it and USEUCOM were being

worked out, planning for the reception and further distribution of patients in the

United States moved ahead. In late December, MAC directed that aeromedical

staging facilities be established at bases selected as reception points for evacuees

from the Persian Gulf: McGuire AFB, New Jersey; Andrews AFB, Maryland.;

Charleston AFB, South Carolina; Kelly AFB, Texas; and Norton AFB, California.

The day after the air war began, CENTAF requested that the aeromedical staging

facilities be activated, and once the ground war commenced in February, MAC

headquarters alerted all to be prepared to receive patients. The three eastern bases

were scheduled to receive the greatest number of patients, with Andrews AFB

being the primary reception center.148

The Test: The Aeromedical Evacuation System

in Desert Storm

In spite of minor but disturbing regulatory problems, notably, patients regulated to MTFs in Germany but arriving at reception airfields in the United

Kingdom, the low level of casualties precluded an actual test of the system. At the

initiation of the ground war, an additional tactical aeromedical evacuation channel had been created. An extremely well-equipped and staffed contingency hospital, the 1702d, was established in the AOR at Seeb, Oman, under the leadership

of Col. P. K. Carleton, formerly on the medical staff at Scott AFB. Part of a joint

Army–Air Force medical complex, the 1702d was tasked to receive patients

directly from the front lines.149 The complex was fruit of Colonel Belihar’s early

search for third-echelon facilities in host nations, and it was far enough from the

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The Persian Gulf War: Test of the Total Force
forward area of the combat zone—a 41⁄2 hour flight by C–130—to almost qualify

as a COMZ facility. It was little used, and after January 22 the TAES was far

busier flying enemy prisoners of war (EPWs) to the rear areas for medical treatment than it was in evacuating U.S. battle casualties.

Some 632 wounded enemy prisoners were transported on nineteen aeromedical evacuation missions beginning in January; a smaller number was transported

on eight combined U.S.–Saudi aeromedical evacuation missions that began on

February 17. The February missions were manned by U.S. aeromedical crews on

nine dedicated Royal Saudi Air Force C–130s specially configured for aeromedical evacuation and flown by Saudi flight crews. Some 82 pan-Arab coalition and

enemy casualties were evacuated either to the single MTF dedicated to enemy

prisoners, the 300th Field Hospital, or to hospital facilities in Saudi Arabia and

other host nations.150 By contrast, of the 7,231 patients aeromedically evacuated

on intra- or intertheater missions (4,856 of them on strategic aeromedical missions

to USEUCOM) from January 17, the start of the air war, to March 31, 1991, only

355 were battle casualties.

Between August 12, 1990, and March 31, 1991, the aeromedical evacuation

system established to support CENTCOM transported a total of 12,632 patients—

5,099 litter and 7,533 ambulatory—on 671 missions. More than half of the total,

415, were intratheater evacuations, and 256 carried 8,121 patients from the AOR

to hospitals in the USEUCOM, CENTCOM’s COMZ.151 On March 4, General

Tenoso directed the 1611th to begin redeployment, and most of its members were

gone by the end of March. On April 7 replacement active duty and ARC personnel from USEUCOM assumed command and control of the remaining aeromedical evacuation force in the AOR.

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Marines evacuating casualties on a C–141 in February, 1991.
Proven Force and Provide Comfort

During Desert Shield/Desert Storm, the focus of medical support to CENTCOM, including aeromedical evacuation, was on the AOR and the forces

deployed there. However, part of the air war against Iraq was conducted by

USEUCOM from Turkey, a NATO member country within USEUCOM’s AOR.

Codenamed Proven Force, aeromedical evacuation support requirements existed

for U.S. air forces deployed to Incirlik and other Turkish air bases. Because no

ground offensive was planned, meeting the high patient movement issue that concerned CENTCOM, CENTAF, and the COMALF in the AOR was moot. Brannon

deployed one of the first seven AELTs activated to Incirlik early in Desert Shield,

but aeromedical support for the fighter units assigned to various Turkish air bases

appears to have been provided by C–9s and medical flight crews from the 2d

AMES. Incirlik had been one of the stops on the theater aeromedical evacuation

channel mission itinerary for many years.152 In the wake of Desert Shield/Desert

Storm, Operation Provide Comfort, the provision of humanitarian assistance to

Kurdish refugees in northern Iraq, generated broader medical and aeromedical

evacuation requirements. Provide Comfort, like Desert Shield/Desert Storm, was

an operation that demanded flexibility in planning and execution of the needed

medical support. For this operation, CINCEUR was the supported CINC.

Iraqi Kurds took advantage of Saddam Hussein’s defeat to mount a rebellion

against control from Baghdad in an attempt to create an independent Kurdistan.

Iraqi forces suppressed the rebellion, particularly relying on the armed helicopters

that CENTCOM had mistakenly allowed Iraq to continue operating. By April 9,

1991, 300,000 Kurds were refugees in the mountains along the Turkish-Iraqi border, others had crossed into Iran, and another 280,000 fled into Turkey. Beginning

on April 6th, the United States with twelve other nations mounted Provide

Comfort to provide humanitarian aid to the refugees who were suffering harsh

weather conditions and a critical lack of potable water, food, shelter, sanitation,

and medical supplies.153

A combined task force of representatives of the participating nations established itself at Incirlik, which became the strategic aeromedical evacuation hub.

USAFE deployed an ATH to Silopi in southcentral Turkey near the Iraqi-Syrian

border where a humanitarian services support base had been established to provide logistic support to two JTFs and other allied forces. The JTFs missions were

to succor the Kurds in the mountains, clear Iraqi forces from northern Iraq, establish transition camps for Kurds brought in from the mountains, and negotiate the

Kurds’ final resettlement in Iraq.154 Aerial reconnaissance revealed groups of

refugees at forty-three separate locations and eleven major campsites. Silopi had

no airfield, and the mountainous terrain throughout the border area placed the primary burden of patient evacuation on Army medevac helicopters, whose responsiveness was hampered by inadequate communications. Initially, rotary-wing aircraft took patients to the Turkish air base at Diyabakir. From there, Blackhawk

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helicopters with extended-range fuel tanks, C–130s, or other fixed-wing aircraft

could evacuate the injured or ill to Incirlik. Even Gen. John R. Galvin’s VIP-configured C–9 was used for an emergency airlift from Diyabakir to Incirlik during

the general’s inspection visit to Turkey. Another general officer’s C–12 Huron was

used for the same purpose, also for a flight from Diyabakir to Incirlik.155

Volunteers from among AFRES medical flight crews who had served in the

1611th deployed to Incirlik in May to provide the crews for aeromedical evacuation flights by the C–130s based there. Within a month, an airfield opened at

Sirsenk in northern Iraq to provide a more direct route to Incirlik. Volunteer crews

who staffed these missions were based in a tent city at Incirlik, but they staged at

Diyabakir for short periods to be readily available for emergency aeromedical

evacuation requirements.156

Neither Diyabakir nor Sirsenk had MASFs deployed, but Incirlik had one. At

Sirsenk were a British combat hospital, a French medical unit, and a U.S. AELT

composed of one Medical Service Corps member from Brannon’s 1st AMES, two

flight nurses, and four medical technicians, all of whom had deployed to Turkey

in May from the Gulf. The Incirlik USAF hospital had been expanded for the

operation, and patients were either held at the hospital for treatment or evacuated

on routine C–9 flights with medical flight crews from the 2d AMES at RheinMain.157

By late July, Operation Provide Comfort was essentially over, and the

Kurdish situation had been stabilized under a no-fly zone enforced by international combat aircraft patrols. Although the 2d AMES from Rhein-Main supported patient lift to Germany from Incirlik, aeromedical evacuation units from the

ARC also played important roles in Provide Comfort as they had in Desert

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Operation Provide Comfort in 1991.
Shield/Desert Storm. The 32d AMEG from Kelly AFB provided the MASF at

Incirlik, and the 74th AMES from Westover AFB, Massachusetts, provided the

medical flight crews for C–130 evacuation flights.158

Conclusion

It seems abundantly clear from talking with many of the senior medical leaders and reading their candid comments to one another in various postwar encounters that, even as they went about developing a medical support system for CENTCOM during Desert Shield, they tended to share the view ascribed to them later

by the CENTCOM deputy surgeon: We aren’t going to do it this way

again!159Facing a situation quite different from the one they might have anticipated during the Cold War years, and with the Vietnam experience rapidly becoming

a distant and not too fond memory, senior surgeons and their medical planners

from all the U.S. services took the tools they had—the doctrine, equipment, mobilization system, and personnel resources of a new total force—and adapted them

to the unique requirements posed by an offensive war in the desert. Not only were

the requirements of offensive war quite at variance with the defensive posture of

NATO, which the United States led, the force mix had changed; U.S. armed forces

were now composed entirely of volunteers, the inclusion of reservists was

absolutely necessary, and jointness was a statutory imperative.

Nowhere was this adaptability more evident than in those who shaped the

aeromedical evacuation system. The General Accounting Office (GAO) was justifiably critical of shortcomings in each of the U.S. services’ medical readiness

programs, including the Air Force’s aeromedical evacuation system, in support of

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A Kurdish refugee camp in 1991.
operations in the Persian Gulf,160 but what does not appear in any of the GAO

reports is the truly remarkable willingness that senior medical leaders had to transcend in breaking down institutional rivalries and conflicting medical doctrines to

fashion a comprehensive medical support system that, although ultimately

unstressed, nevertheless appears in retrospect to have been capable of meeting the

challenge.

Regarding medical cooperation in Desert Shield/Desert Storm, one extremely knowledgeable observer of contemporary military medicine observed recently

that whatever it was, it wasn’t joint.161 Compared to admittedly smaller but

nonetheless illustrative events involving medical practitioners from different services prior to the 1986 GNA, military medicine in the Persian Gulf War represents

a quantum leap forward in jointness that evolving trends in world conflict seem to

demand.

An effective aeromedical evacuation system was the critical link in the medical support system. Perusal of the GAO criticisms of the CENTAF aeromedical

evacuation system suggest that investigators used a snapshot approach rather than

evaluating how the system had evolved and what its actual capabilities were on

the eve of the ground war. Citing, sometimes erroneously, individual deficiencies

identified in Brannon’s after-action report, the GAO does not evaluate the report

as a whole. It does not assess the cumulative effect of the remedial actions that

Brannon describes were taken to correct deficiencies and create what appears to

have constituted an effective system when the ground phase of Desert Storm

began.

Brannon simply does not state in his after-action report, as the GAO asserts,

that “the predicted flow of casualties would have overwhelmed the aeromedical

evacuation system because not enough aircraft were allocated to evacuate

patients.”162 This is the conclusion that the GAO investigator drew from Brannon’s

theoretical calculations of the number of C–141s needed to evacuate the predicted number of patients, given assumptions about the number of available aircraft,

the evacuation policy, and other important factors that the investigator implicitly

accepts as accurate and immutable. Similar conclusions regarding the probable

collapse of the aeromedical evacuation system must also be taken skeptically.

After the fact, although the whole issue regarding possible collapse of the

aeromedical evacuation system is ahistorical because it was never stressed as predicted, experienced observers have expressed their belief that the system could

have handled the peak loads as predicted. These observers include the USEUCOM surgeon who went on to become surgeon general of the Air Force, the senior

CENTAF medical planner, and MAC’s director of Medical Readiness and

Evacuation.163 The Gulf War Air Power Survey comment that the intertheater evacuation system was probably incapable of handling such a load without major reinforcements and workarounds may be quite correct; however, the capability for

allocating additional aircraft and crews, if required, was real, according to the

MAC commander, and the USAFE surgeon’s reasonable concerns about the avail230

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ability of patient-care equipment ignored the extremely large amount of such

equipment that did in fact arrive in the AOR in January and in the CENTAF MEDSOM at Thumrait, of which the USAFE surgeon admitted after the war that he

was unaware.164

Brannon’s after-action report not only describes the evolution of the

aeromedical system from its modest beginnings in August to the peak of its capabilities on the eve of ground hostilities, it very consciously lays out what capabilities an aeromedical evacuation system will require in any future similar conflict.

The aftermath of the Persian Gulf War would reveal whether the lessons Brannon

drew from the event and the prescriptions he made in his after-action report would

be seen to be applicable to the inevitable reengineering that the aeromedical evacuation system would receive.

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A History of Aeromedical Evacuation in the U.S. Air Force
Chapter 10

EMERGENCE OF THE POST–GULF WAR

AEROMEDICAL EVACUATION SYSTEM:

TRENDS, ISSUES, AND BUREAUCRACY

Institutionalization of the Desert Storm/Desert Shield

Aeromedical Evacuation Experience

The medical components of the U.S. Army, Navy, and Air Force shared common experiences during Desert Shield/Desert Storm providing the basis for a new

paradigm upon which to base the organization of a more truly joint aeromedical

evacuation system. Whether each service would draw the same lessons learned, or

whether there would be internal agreement within the individual services as to

what the proper lessons were, also remained to be seen. The events of Desert

Storm would, however, provide a powerful impetus toward further realization of

the objectives of the GNA.1

Some lessons, such as the relative lack of mobility of DEPMEDS combat

support and MASHs in the CENTCOM AOR, were immediately obvious, and the

Army Medical Department quickly dealt with the problem. As an immediate solution, it formed forward surgical elements and teams, FSEs and FSTs, from its

combat support hospitals and began to lighten the DEPMEDS. Other apparent

lessons, such as the widely voiced conviction by many Army veterans of the Gulf

War that the Army required a new fixed-wing, medium-range aircraft with short

takeoff and landing characteristics for medevac, were somewhat more problematic and implicitly threatened to resurrect controversies with the Air Force over

roles and missions.2 A serious move by the Army to procure such an aircraft would

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surely provoke Air Force resistance as well as undoubtedly irritate C–130 pilots

who had flown aeromedical evacuation in the Gulf, considering that Army

Medical Corps personnel had publicly praised the Air Force’s willingness to send

its C–130s forward of second-echelon MTFs to retrieve casualties.3

Not all potential customers in the AOR were positive about their experience

with the Air Force and the TAES. One was Cmdr. Gary Breeden, the naval officer commanding the 1st Medical Battalion of the Marine Corps’ 1st Service

Support Group. His medical battalion deployed six second-echelon MTFs close to

the Kuwaiti border in support of CENTCOM’s marine component, and the

CENTCOM surgeon’s plans were that Air Force C–130s would conduct patient

evacuation to the fleet hospitals near al-Jubayl. Based on the Air Force’s record in

evacuating patients from his forward hospitals during the short ground war,

Breeden, who became the USTRANSCOM deputy command surgeon, thought

the service promised more timely evacuation support than it could deliver.4 His

comment about Air Force support to his hospitals may have reflected unique problems rather than inadequacies in the TAES as a whole, but the issue was valid and

had implications for future conflicts. The availability of airlift to meet aeromedical requirements was an issue the Air Force had to address, considering General

Tenoso’s difficulties in implementing his decision to use two squadrons of C–130s

for aeromedical evacuation during the period of actual hostilities.

Historically in large-scale modern wars, tension exists between requirements

to use airlift for operational support of the combat forces and the aeromedical

evacuation of casualties. Desert Storm proved no exception. Looking back on

events, General Tenoso indicated he would have found it impossible to honor his

commitment because even the relatively short ground war had generated heavy

tactical airlift requirements.5 Whatever might have occurred in a longer ground

war incurring heavier casualties, the theme sounded by many Army medical veterans of Gulf operations and the senior marine, General Boomer, reflected the

reality that Desert Storm revealed serious potential shortcomings in the chain of

evacuation for Schwarzkopf’s forces.6

Aside from medical readiness, this issue had budgetary implications that

were not inconsiderable. The steady decline in the overall defense budget that predated the Gulf crisis had only temporarily been arrested with the heavy expenditures necessitated to cover the costs of U.S. involvement, even though the United

States’ costs were partially recovered from Saudi Arabia. Declining budgets had

only heightened pressure on each service to develop more efficient methods for

organizing, deploying, and supporting combat forces, and, indirectly, to attain

greater jointness.7

In this regard, several specifically Air Force issues could have proven central

to how aeromedical evacuation might be conducted in future contingencies. For

example, would the MAC policy of requiring MTFs to hold patients long enough

for them to become clinically stable be reaffirmed in the postwar period? The policy stated that if unstable patients required emergency aeromedical evacuation,

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the MTFs from which they came must provide accompanying attendants and lifesustaining equipment. This procedure had been blurred somewhat because AE/FS

had been present on most aeromedical evacuation flights within the AOR. The

surgeons could intervene medically if the condition of a stabilized patient deteriorated unexpectedly, and their presence had allowed the transportation of “greener” patients than MAC normally carried. Flight surgeons also provided insurance

against the possibility that casualties might have to be evacuated quickly in such

high numbers that forward MTFs would be overwhelmed. It remained unclear

whether the Air Force would change its doctrine to place flight surgeons or other

physicians routinely on aeromedical evacuation missions in future contingencies.

An implication derived from the possibility of providing critical care in the

air was that forward medical support required could be reduced, just as the Army

surgeon general had thought (and feared) the experience of Operation Just Cause

might indicate to an economy-minded Congress. The fact that the Army deployed

relatively small FSEs and FSTs in Desert Storm, when coupled with the speed

with which patients could be (and were) aeromedically evacuated from the AOR

to the CONUS after surgical intervention, could be seen to foreshadow such a

change. It was also obvious that the MAC requirement that MTFs provide medical personnel and equipment to accompany unstable patients would be impossible to sustain in a large-scale contingency when large numbers of casualties had

to be evacuated after initial resuscitative surgery.

This MAC requirement also had implications for the sensitive internal sociology of the Air Force Medical Service. If the lesson taken from the Gulf War was

that physicians should fly routinely on aeromedical evacuation missions, implementing such a policy could create friction between physicians and flight nurses,

who since the end of World War II had routinely served as MCDs responsible for

overseeing aeromedical evacuation missions. General Tenoso notes that reports of

friction between some flight nurses and Mabry’s flight surgeons over who was in

charge while in the air had occasioned lively discussions in Riyadh among senior

officers who were responsible for these evacuations.8

During Desert Shield/Desert Storm, this was a control rather than a medical

issue because flight surgeons routinely flew on all aeromedical evacuation missions. An underlying issue was the AMC policy that authorized an MCD to reject

patients for aeromedical evacuation who were not clinically stable, but how was

stable to be defined, and was stable defined differently in peacetime that it was

for the wartime movement of patients? The answer to these questions would

largely determine whether the standard AMC medical flight crew under the direction of an MCD would require augmentation by physicians and/or intensive-care

specialists during evacuations. The authority of the MCD had evolved as a reflection of the increased sophistication of nursing skills and MAC’s primary focus on

strategic, intertheater aeromedical evacuation, which generally did not have the

urgency generated by aeromedical evacuation in a tactical situation. The authority of the nurses had come a long way from the emergence of aeromedical evacu235

Trends, Issues, and Bureaucracy
ation in World War II when the tactical situations and physician-nurse relationships were different. As one of the pioneering flight nurses who landed on

Guadalcanal in March 1943 put it many years after the event, doctors provided the

patients for evacuation, and “we took all the wounded since there wasn’t any kind

of real hospital on the island.”9

Whether a patient was stable for movement generally involved considering

several aspects of his or her medical condition, including free breathing, controlled bleeding, treatment of shock, and hydration. For peacetime evacuation, the

condition of a patient was considered against certain specific criteria in some

twelve categories to determine whether the individual was stable for routine

movement by air. After abdominal surgery, patients might travel on the fifth day

after their operation if they were functioning physiologically and experiencing no

complications. Anemic patients who had a hemoglobin value less than seven

might require that the aircraft fly below a certain altitude, or they might require

oxygen or transfusions. Patients who had experienced a cerebrovascular accident

were not to be routinely moved until seven days after their bleeding had ceased

and they showed no subsequent complications. For those with fractures, fresh

casts should be between forty-eight and seventy-two hours old and applied with

allowance for tissue expansion. For wartime evacuations, the criteria were somewhat more subjective and focused on the professional judgment of the responsible physician. As defined by the JCS Medical Steering Committee in 1985, a stable patient was

one who, in the clinical judgment of the responsible physician,

can withstand a bed to bed evacuation of 6–24 hours without

sustaining complications requiring invasive treatment of intervention beyond the scope of general supportive care during

evacuation.10

In practical terms, the MCD of a standard AMC flight crew generally would not

accept a patient for evacuation if the care required in the air during the evacuation

was beyond the clinical skill of the medical flight crew under the MCD’s direction.11

For patients who were stabilized—patients who received resuscitative

surgery were not to be considered stable for either peacetime or wartime movement, but if intensive care could be provided during the flight, they could still be

evacuated by air—augmentation of the standard flight crew was necessary. Flight

surgeons provided such augmentation for the flight crew, although not all were

trained in critical-care specialties. An aeromedical evacuation flight crew consisted of two flight nurses, the senior one serving as the MCD, and three enlisted

medical technicians. In peacetime, MCDs generally required that augmentation be

provided before accepting stabilized rather than stable patients, a prime example

being the general rule that a respiratory therapist accompany a patient who

required a ventilator to breathe.12

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Other important issues and questions arising affecting aeromedical evacuation demanded resolution. Perhaps the major one was how to use the Gulf war

experience to improve the aeromedical evacuation system within what would

prove to be a much more dynamic context than even the end of the Cold War

would have suggested. The 1611th AMES commander’s report was an obvious

starting point. Colonel Brannon deliberately intended that his encyclopedic afteraction report be more than the usual narrative of events. He included a comprehensive description of the problems and issues that arose in establishing an

aeromedical evacuation system for the Persian Gulf operations, its actual operation during Desert Shield/Desert Storm, and the ways in which problems and

issues that had arisen were successfully addressed. His report also offered recommendations intended to achieve a reengineering of the Air Force aeromedical

evacuation system to prepare it to function more efficiently in a future contingency. Many lessons from Desert Shield/Desert Storm would have seemed familiar to those involved with aeromedical evacuation since World War II, problems

like litter availability and inadequate communications regarding patient movement between echelons of care.

These and other similar issues, many of them discussed in Brannon’s report,

might be termed generic with regard to changes necessary to improve aeromedical evacuation procedures. Some could be addressed by the service principally

concerned through budgetary decisions, policy changes, and new training programs, although the heavy emphasis on jointness placed tacit limits on purely unilateral solutions. The C2 system for theater evacuation might have appeared to be

an area for unilateral Air Force action, given the initial confusion about the nature

of command relationships in the C2 of the TAES. Was this confusion inherent in

the way the C2 system was established, and if so, would changes make the

aeromedical evacuation system more efficient and more effectively joint? A consideration of the larger C2 structure within which the TAES established command

and control is necessary to address the question.

The aeromedical evacuation system supporting CENTCOM during Desert

Shield/Desert Storm consisted of a mixture of active duty and reserve organizations operating within a command structure at whose apex was the commander

exercising combatant command (COCOM)—the supported CINC in joint operations—who assigned the operational mission. When the aeromedical evacuation

organizations were called to active duty, they deployed to the AOR and USEUCOM. The Air Force aeromedical evacuation capability overwhelmingly resided

in the ARC, under MAC Commander General Johnson. He did not nor could he

exercise COCOM.13 After the aeromedical evacuation units formally arrived in the

AOR, the CENTCOM commander assumed COCOM. The membership of these

ARC units, together with members from the MAC active duty AMESs, over

whom the MAC commander also exercised command, less COCOM, was composed of the provisional unit of MAC, the 1611th AMES that Colonel Brannon

commanded in the AOR. The CENTCOM commander, General Schwarzkopf, the

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joint force commander charged with the mission of defending Saudi Arabia and

expelling the Iraqis from Kuwait, exercised COCOM of the 1611th through the

Joint Force Air Component Commander (JFACC), General Horner. Horner exercised operational control of both the 1611th and the tactical airlift forces sent to

the Persian Gulf through the COMALF, General Tenoso.14

Whatever the seeming complexity of these organizational relationships, the

positive personal relationships among the principals made the theater aeromedical

evacuation system work. To the degree that there some initial confusion existed

among them, not least between Generals Tenoso and Randolph about how authority was distributed within the system, it was rooted in the senior players’ lack of

previous experience with the new system. The fault lay not necessarily in the system itself. The C2 structure for aeromedical evacuation was merely a subset of the

larger C2 system for the joint air forces, which was also being exercised for the

first time by General Horner in his role as the JFACC.

As one evaluates the effectiveness of aeromedical evacuation during Desert

Storm, a potentially bigger issue than the C2 system was whether sufficient airlift

would have been available to move the larger numbers of casualties that

Schwarzkopf’s forces might have incurred had they engaged in more extended

ground combat with the Iraqis. Although this is moot because of the war’s early

termination, an indication that USTRANSCOM had concern that the available

airlift might not have been sufficient was its postwar decision to assign civil aircraft to stage two as well as stage three of CRAF’s aeromedical evacuation segment. The intent was to augment its strategic aeromedical evacuation capabilities

earlier in a crisis.15 Having CRAF 767s available earlier in the conflict for transatlantic evacuations would have increased MAC’s confidence that other priorities

would be less likely to override its decision to retain dedicated C–141s to move

patients from the AOR to the COMZ.

Although questions regarding the availability of sufficient airlift to support

the aeromedical evacuation system might have been moot, what was definitely not

moot was the fact that medical regulating for even the relatively small number of

casualties who had been evacuated from the AOR to the COMZ in Europe had by

all accounts been demonstrably inadequate.16 Medical regulators for CENTCOM

lay outside the aeromedical evacuation system because the JMRO at Riyadh and

a subarea JMRO in Bahrain were joint organizations reporting to the Joint

Force/CENTCOM surgeon, Colonel Belihar. Additionally, Army and Air Force

medical regulators serving with their third-echelon medical units functioned as

requestors for aeromedical evacuation. Complicating the medical regulation

process for Desert Storm was the fact that the Riyadh JMRO formally interacted

with the USEUCOM JMRO at Rhein-Main, and the regulators did not always

agree on the process to be used. According to a senior MAC staff member who

helped establish the ad hoc push system for regulating casualties from the AOR to

contingency hospitals in Great Britain and Europe, one of the Rhein-Main regulators argued strongly that he could handle the regulation of patients from the Gulf

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area even if their number reached the highest level projected—a position with

which no one else involved in the process reported any confidence.17

The perceived need to bypass the normal contingency medical regulating system for Desert Storm and the disappointment expressed about the deficiencies and

confusion of the medical regulating that did occur made the regulating system a

prime candidate for improvement. MAC and AMC, its successor organization

after July 1992, considered how the aeromedical evacuation system should be

reengineered, particularly with an eye toward injecting in-transit visibility of

patients. Proposals to change medical regulating could well prove contentious.

The Army had opposed ASMRO’s earlier move to Scott AFB and the designation

of the Air Force as its executive agent.18 Changes that might appear to increase an

Air Force role might trigger some lingering discontent. Medical regulating was a

joint function, and USTRANSCOM, rather than the Air Force, was the natural

agent for achieving change. This was a role that General Johnson actively sought

and one his successors pursued, who as dual-hatted USTRANSCOM and AMC

commanders were assigned the task of improving the aeromedical evacuation system.

Another approach to increasing the efficiency of aeromedical evacuation in

future contingencies might involve further rationalizing the C2 of the worldwide

aeromedical evacuation system for which MAC had been assigned responsibility

in 1975. MAC had assigned management of the system to the commander of the

375th Aeromedical Airlift Wing, and his wing surgeon served as the wing’s

deputy commander for aeromedical evacuation. The 375th controlled the active

duty aeromedical evacuation squadrons of nurses and medical technicians worldwide and the single domestic aeromedical airlift (flying) squadron based at Scott.

The aeromedical airlift squadrons deployed in Europe and the Pacific were under

the operational control of the respective theater commanders, which meant separate reporting chains controlled the personnel and the aircrews who flew the missions.

Months before the beginning of the Persian Gulf crisis, General Johnson, the

then-new USTRANSCOM commander, had evaluated the MAC system as organizationally too complex and confusing to the Air Force line organizations it

served. Consequently, he eliminated the 375th’s role and directed that operational

control of the aeromedical evacuation and the aeromedical airlift squadrons

devolve to the airlift wings at which the active duty aeromedical evacuation units

were based. Thus, wing commanders at Yokota AB and Rhein-Main AB assumed

operational control of their respective evacuation units in addition to their airlift

units. The aeromedical evacuation squadron commanders became wing deputy

commanders for aeromedical evacuation. In the CONUS, the 317th Wing commander at Pope AFB assumed operational control of Brannon’s 1st AMES.19

Because General Johnson vested his command surgeon with administrative command of the aeromedical evacuation units worldwide, it gave the command surgeon control of training, personnel assignments, medical policy, and standardiza239

Trends, Issues, and Bureaucracy
tion, thus preserving centralized management of the system. This attempt to introduce a measure of decentralization while preserving the seamless nature of the

worldwide aeromedical evacuation system would not last beyond the Persian Gulf

War.

Reengineering the Aeromedical Evacuation System:

Initial Steps

The task of reengineering the aeromedical evacuation system in the Air Force

was given to General Roadman who in October 1991 became the dual-hatted

command surgeon of USTRANSCOM and MAC. His USTRANSCOM deputy

surgeon was Navy Comdr. Gary Breedon, who had commanded the 1st Medical

Battalion in the Gulf AOR. Colonel Bloomquist, who had strong views on how

MAC’s aeromedical evacuation system should be reengineered, retained his position as chief of Medical Plans and Aeromedical Evacuation.

Other senior Air Force Medical Corps officers with direct experience of the

medical support created for CENTCOM were also reassigned in the post–Desert

Storm period to positions in which their experience could be valuable in restructuring not just aeromedical evacuation but the entire area of contingency medical

support. Alexander “Rusty” Sloan, the USEUCOM surgeon, was promoted to

lieutenant general and surgeon general of the USAF, and Col. Leonard Randolph,

the CENTAF surgeon, was promoted to brigadier general and made CENTCOM

surgeon. His predecessor, Colonel (later Brig. Gen.) Belihar was reassigned to the

Air Force Military Personnel Center. The former COMALF, General Tenoso,

became USTRANSCOM’s Director of Operations/Logistics (J–3/J–4).20

Colonel Carleton, who had developed the Air Force contingency hospital at

Seeb in the UAE during the war, was assigned to the USAF’s Air Education and

Training Command as deputy chief of staff for Medical Services and Training.

Carleton, who would later command the Air Force’s premier medical installation,

the Wilford Hall Medical Center at San Antonio, and succeed General Roadman

in September 1999 as surgeon general of the Air Force, had strong views on

aeromedical evacuation and was an influential voice in the matter, both during the

Gulf War and after its conclusion.21

As USTRANSCOM/MAC command surgeon, Roadman was ideally suited

temperamentally and as a result of his recent experience to direct improvements

in the aeromedical evacuation system. He had successfully directed creation of an

ad hoc system to provide limited in-transit visibility for patients who entered the

USEUCOM theater evacuation system. According to officers who worked for

Roadman at AMC, he was extremely competent and focused, always businesslike

with his subordinates, extremely thorough and demanding, and admired for his

strong sense of mission. One former medical planner in the MAC surgeon’s office

noted that he had learned more from Roadman than he had from any other command surgeon with whom he had worked.22

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Roadman’s assignment was eminently logical in view of his active involvement with the aeromedical evacuation system as the USAFE surgeon during the

Gulf crisis. More importantly, General Johnson specifically requested him.23 Dualhatted as commander of MAC and USTRANSCOM, Johnson was keenly aware

of his command responsibility for both strategic and tactical aeromedical evacuation. However, he was extremely concerned about his lack of control over all elements of the relevant systems that the Gulf experience had demonstrated.24 He

consequently sought Roadman’s assignment not only for his role in Desert Storm

but because he considered Roadman to be the best-qualified Air Force medical

officer for dual command who could aggressively pursue his objectives regarding

aeromedical evacuation.25 According to Johnson’s vice commander, Lt. Gen.

Robert Rutherford, who relayed the comment to the newly arrived Roadman, the

USTRANSCOM commander considered aeromedical evacuation “the single

most important subject on your plate.”26

Even before General Roadman arrived at Scott AFB, General Johnson had

initiated the reengineering process. On July 23, 1991, some five months after the

end of the ground war, Johnson’s deputy commander, Army Lt. Gen. Dane

Starling, invited representatives of the joint staff, commands, and concerned agencies to the initial organizational meeting of a joint casualty evacuation working

group (JCEWG) to be held from October 8th to 10th at Scott AFB. Starling’s letter stated the JCWEG’s purpose was to “review issues of resource commitment

and patient in-transit visibility appearing in lessons learned from Operation Desert

Shield and Desert Storm.”27 From USTRANSCOM’s perspective, the major goal

was to explore how acceptable the conferees would find USTRANSCOM’s control of worldwide medical regulating. USTRANSCOM also hoped to establish

permanent working groups to address joint casualty evacuation issues after the

Desert Storm experience and with a view to the future.28

General Johnson and the USTRANSCOM surgeon’s office were extremely

pleased at the results of this first working group. Support for USTRANSCOM’s

proposal to take control of medical regulating was well received, with only

PACOM and the Air Force surgeon general’s representatives initially in dissent.

The former offered the curious comment that it would be too incestuous for medical regulating to belong to the transporters, while the latter stated no rationale.

The conferees did eventually agree that

Armed forces need a single integrated data system for worldwide medical regulating that operates in both peace and war.

The system should provide simultaneous access by all Joint

Medical Regulating Offices (JMRO) and the Armed Services

Regulating Office (ASMRO) and provide for in-transit visibility of patients.29

Additionally, to replace the current fragmented system, the conferees recommended that USTRANSCOM staff30 a proposal to the JCS through the theater CINCs

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and services that would allow it to assume an effective level of COCOM and operational control, and/or responsibility for medical regulating worldwide. While

USTRANSCOM did this, the Joint Staff Logistics Directorate’s (J–4) Medical Readi -

ness Division would prepare and staff a joint doctrine paper to address joint casualty

evacuation issues arising in joint contingencies, like Desert Storm.31 The conferees

also established two JCEWGs: one to handle joint issues; the other to work toward

integrating and improving the data systems associated with medical regulating.

Buoyed by their success, by early February General Roadman’s staff, led by

Breeden, prepared a draft of the proposal recommended by the JCEWG and

secured concurrence of the remaining USTRANSCOM directorates. After agreement within USTRANSCOM, the proposal was briefed to a meeting hosted by the

J–4 Joint Staff Medical Readiness Division, which included representatives from

the U.S. Army Forces Command surgeon general’s office. The conferees supported the proposal, and by February 24, 1992, the USTRANSCOM staff’s draft had

also secured the support of the surgeons general of the Army and Navy as well as

the deputy ASD for Medical Readiness, thus moving the USTRANSCOM proposal significantly toward final approval by the Secretary of Defense.32

The USTRANSCOM proposal called for providing centralized global management of patient movement by integrating what heretofore had been the separately controlled processes of medical regulating and aeromedical evacuation. The

formal process for moving a patient from one theater to another had been that the

sending JMRO first ask the receiving JMRO to designate an empty bed for the

patient in an appropriate MTF, wait for an answer, and only after receiving one,

coordinate with the AECC for space on an aircraft to evacuate the patient. The

USTRANSCOM proposal would create and manage a database containing all

DoD bed status information (which it termed a reservation system) from which

each supported JMRO could itself identify an appropriate bed for each patient and

coordinate the required airlift with the supported AECC. The necessary data

drawn from separate DMRIS databases would be uploaded on the Global

Transportation Network, USTRANSCOM’s C2 system then in development,

which would contain data providing in-transit visibility of the personnel and

equipment being transported by USTRANSCOM aircraft.

Johnson’s intent was to acquire control over strategic aeromedical evacuation, and the USTRANSCOM proposal specifically retained the theater CINCs’

control over their JMROs and intratheater medical regulating and aeromedical

evacuation missions. USTRANSCOM proposed managing the integrated regulating and aeromedical evacuation system through a new organization over which

the TRANSCOM commander would have authority. In formal organizational

terms, it would be a USTRANSCOM direct reporting unit created by merging the

ASMRO and AMC’s PAC (the old AECC), both located at Scott AFB.33

Over the next several months, USTRANSCOM aggressively pursued securing the necessary final coordination by the services and the CINCs, working with

the J–4 Deputy Director for Medical Readiness Rear Adm. Joseph Smythe, who

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favored the proposal. Perhaps predictably, service comments included an alternative proposal that ASMRO be assigned to the Army joint specified command,

Army Forces Command, that had responsibility for nationwide medical support if

the United States went to full mobilization, rather than to USTRANSCOM.

Surprisingly, the Air Force surgeon general’s office objected to the role

USTRANSCOM proposed for itself as manager of an integrated worldwide medical regulating system. The office characterized the proposal as adding unneeded

management changes to what it saw as the basic solution to the regulating problems revealed during Desert Shield/Desert Storm and identified in

USTRANSCOM’s proposal, the “improved automation systems” to which end

efforts were “now underway.” The surgeon general’s office did see merit in merging ASMRO with PAC for CONUS operations.34

In early June, Roadman wrote Admiral Smythe to rebut these objections vigorously, pointing out that the automation improvements cited by the surgeon general’s office as underway were either part of the USTRANSCOM proposal, on

which USTRANSCOM had already been working with the DoD Director of

Defense Information for six months, or were complementary to it, namely, theater-focused initiatives to integrate TAMMIS with DMRIS, whose database

allowed a theater JMRO to track and manage its own hospital beds and field an

automated data storage card for patients. Roadman pointed out that the proposed

fundamental change to medical regulating, together with the required global connectivity and accompanying automation improvements, created by default a “previously nonexistent global command and control (C2

) system for seamless

intertheater medical regulating and aeromedical evacuation of patients,” and it

was this new intertheater C2 system that would require a single global manager or

command.35 Roadman’s arguments carried the day, and the Director of the Joint

Staff forwarded the USTRANSCOM proposal to the theater CINCs a week later

for their approval. By the end of that month, all had done so, and the CJCS then

approved the concept of the new USTRANSCOM mission, an indication of the

strong support that USTRANSCOM’s proposal had gathered.36

General Johnson’s quest to have USTRANSCOM gain control of intertheater

medical regulating was finally realized by his successor, Gen. Ronald Fogleman,

with the issuance of DoD Directive 5154.6 on April 29, 1993. The directive made

the USTRANSCOM commander the DoD single manager for implementing policy and standardizing procedures and information support systems for intertheater

medical regulating. It granted USTRANSCOM authority to regulate patients from

combat theaters into other theaters, and it gave USTRANSCOM authority over

ASMRO; it affirmed the responsibility of the theater JMROs or surgeons for

intratheater regulating; and it directed USTRANSCOM to provide for the establishment of a C2 system for global patient movement and patient in-transit visibility, decentralizing control to the supported CINCs. USTRANSCOM responded by

initiating a development program named the USTRANSCOM Command and

Control and Execution System (TRAC2

ES).37

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In pursuing General Johnson’s objective of securing control of medical regulating, the USTRANSCOM surgeon, General Roadman, and his deputy, Com -

man der Breeden, had successfully established a link to the so-called Corporate

Information Management (CIM) project directed by Dr. Paul Strassman, a wellfunded and powerful DoD official who was the Director of Defense Information.

Based on a successful business career, Strassman received a charter from the

Secretary of Defense to apply new business management principles to the DoD’s

command, control, communications, and intelligence (C3I) information system,

improve its effectiveness, and save $70 billion by FY 1997.38

CIM involved applying a rigorous analytical methodology to C3I problems to

develop so-called business process improvements. USTRANSCOM’s proposal

appealed to Strassman’s staff as a potentially successful case study that could validate the value of the CIM project. It could demonstrate how the total quality management (TQM) approach to producing a product in the civilian business world

could be applied successfully to military organizations. Quality in the TQM sense

was something General Johnson began to implement in MAC in the mid-1990s,

and General Roadman demonstrated his own commitment to TQM soon after

becoming command surgeon.39 In the USTRANSCOM case, the TQM objective

was to change medical regulating and patient movement processes to improve the

transport of patients in peace and war.40

Strassman’s office allocated a significant grant to USTRANSCOM to help

fund the required analytic work. In a display of true hands-on leadership, both

General Roadman and Commander Breeden spent two hours daily for fifteen

weeks participating in CIM workshops, together with other members of the

USTRANSCOM staff.41 Successive workshops, under the rubric of

“Administrative Support of Medical Evacuees Business Process Improvement,”

were conducted from late November 1992 to June 1993. These modeled and analyzed the existing regulating and evacuation processes as a baseline, identified

improvement opportunities and requirements, and developed a strategy for measuring costs that was then used to determine the benefit of functional process

improvements for related investments in information technology.42 The high-priority issues identified by the analyses validated the abundant comments of participants in the Gulf War and other anecdotal evidence available. The workshops

found:

efficient medical regulating and patient evacuation decisions

are impossible because accurate, timely information is not

available;

neither USTRANSCOM, the CINCs, and their service components have visibility of critical medical resources needed to

forecast shortfalls and prevent bottlenecks in the patient evacuation process;

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DoD requirements and public expectations demand in-transit

visibility (ITV);

manual data entry to support by-name medical regulating and

ITV during contingencies is a practical impossibility;

lack of available communications and information resources

place severe operational constraints on medical regulating and

patient evacuation systems; and

peacetime medical regulating and patient evacuation are at variance with wartime/contingency practice and policy.43

The quality of these analyses and the ongoing TRAC2ES development earned

the plaudits of Strassman’s office and the ASD for C3

I, who chose TRAC2ES as

the best example of DoD business reengineering to present to the deputy Secretary

of Defense. The National Business Process Review Conference ’94 recognized

USTRANSCOM’s effort to improve the medical regulating and aeromedical

evacuation processes as one of the federal government’s best examples of business process engineering.44

Success brought unforeseen complications for the further development of the

system. General Johnson’s objective had been to secure control of intertheater

medical regulating. In an inspection report of September 1993, the DoD IG reported on his evaluation of DoD’s ability to provide adequate medical support for military mobilization contingencies, and he singled out TRAC2

ES for praise and recommended it for expedited development “to provide for the needs of both intraand inter-theater patient movements and the information needs of the medical personnel and casualty programs of all services.” He requested that within sixty days

USTRANSCOM provide a schedule with the times of key events identified for

the development and fielding of the new system, which presented a more complex

challenge.45

Improving Aeromedical Evacuation:

MAC Assesses Internal Changes

With its medical regulating proposal, USTRANSCOM had assumed the lead

in what was inherently a joint area. The JCEWG conference and the proposals

advanced by the command surgeon’s office were paralleled by efforts at MAC

headquarters to assess how MAC could improve its own processes to better execute its responsibility as the DoD executive agent for aeromedical evacuation. As

the commander of MAC, General Johnson tasked his deputy chief of staff for

Quality Support and Readiness to conduct an independent assessment of MAC’s

worldwide aeromedical evacuation system and to recommend corrective actions.46

Between August 9 and 13, 1992, a team of four experienced officers, two

with line operational experience and two from the MAC surgeon’s medical plans

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office, conducted the required assessment after thoroughly reviewing all available

background data. They reviewed Desert Shield/Desert Storm after-action reports

dealing with aeromedical evacuation issues; 549 items from the Joint Staff’s Joint

Universal Lessons Learned System dating back to 1983; a so-called Aeronautical

Evacuation Tiger Team47 trip report of 1989 from the 375th Aeromedical Airlift

Wing; and the medical sections of Admiral Long’s report on the Beirut bombing

of October 1983. The assessment team developed some twenty-seven questions

that were sent to all active duty and MAC-gained aeromedical evacuation units in

the ARC, and the units were required to respond. During the assessment, the team

conducted a series of field visits to selected aeromedical evacuation units from

both components. They also attended an aeromedical evacuation working group

conference in late August that General Roadman hosted.48

The team’s thirty-one-page report is impressive both by virtue of the evident

thoroughness of its investigations and its candid portrayal of the strengths and

weaknesses of the aeromedical evacuation system. The team keyed their observations and discussions to their questionnaire and produced twenty-seven recommendations. General Johnson’s interest and careful reading is evident from his

sometimes forceful annotations that appear throughout. In addition, he wrote further questions and comments on the transmittal document, characterizing the

team’s product as a good assessment.49

Johnson pointed to another aspect of aeromedical evacuation that he believed

had to be addressed if MAC was to be able to program the correct amount of funds

for personnel, their training programs, and the equipment necessary for the command to conduct its mission: the joint requirement for aeromedical evacuation,

that is, knowing how many patients would have to be evacuated during a contingency. From his perspective, Johnson believed that MAC had too many aeromedical evacuation crews, and in a kind of reverse echo of General Ledford’s concern

about the Air Force success during Operation Just Cause in evacuating casualties

immediately following emergency surgery without encountering adverse clinical

outcomes, Johnson wrote that MAC’s aeromedical evacuation capability should

not be increased to meet others’ shortfalls.50 Although others were not identified,

Johnson was obviously referring to the possibility that budgetary pressures might

drive the Army to reduce the numbers of deployable third- and fourth-echelon

MTFs, thereby compelling a theater to set an unreasonably short evacuation policy that would drive aeromedical evacuation requirements upward.

Although the assessment team made twenty-seven specific recommendations

based on its prior questioning, it identified eight general areas that were ripe for

improvement efforts, noting that many were not new.

Training: The team recommended establishing a formal AE

“schoolhouse,” pointing to the deficiencies of the largely unit

training and materials then in use that had forced Brannon to

institute training programs in the Gulf AOR. (Gen. Johnson

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wrote, “I strongly agree” by the “schoolhouse” recommendation. Knowingly or not, the team recommended a precise analogue to the WWII School of Aeromedical Evacuation established at Bowman Field, Kentucky, in 1942.)

Organization: The team pointed out that the current peacetime

AE structure did not change smoothly to accommodate largescale contingency operations such as Desert Shield/Desert

Storm or provide in the contingency structure the administrative and support functions needed by the ARC units that composed 93 percent of MAC’s AE capability.

Equipping: AE contingency kits needed to be standardized and

available at all times to units for effective, hands-on training.

Exercising: The participation of all AE units in JCS exercises

should be increased.

Command and control: The peacetime reporting channels for

flight and medical crews differed and hindered understanding of

AE operations by the line community as well as the reverse.

Operations: The team noted that, whereas C–141 ARC AE units

had the opportunity to fly peacetime missions with actual patients,

C–130 ARC units had none and needed training with live patients.

Formal schools: The quotas that were needed to permit AE personnel to attend USAF schools such as airlift operations and

joint contingency warfare planning were too small for such personnel to develop proper understanding of AE in the context of

contingency operations as a whole.

Inspections: The absence of readiness inspections for ARC AE

units such as the operational readiness inspections (ORIs) that

line units received precluded accurate assessments of the ARC

units’ combat readiness posture.51

The major objective of these recommendations was to improve the readiness

and medical effectiveness of MAC’s aeromedical evacuation capability as an

essential element of the U.S. total force. The means included better, standardized,

and more realistic training and inspection of the ARC units in which evacuation

capability predominantly resided. There also appears to have been an implicit

intent to elevate the aeromedical evacuation mission to a higher status within the

command by breaking down barriers between line airlift forces and aeromedical

evacuation, much as General Johnson had sought to do by his October 1, 1990,

removal of the 375th’s control over aeromedical evacuation as a step in impressing quality on MAC.52 In his response to General Johnson’s annotations, the command surgeon assured the CINC that his office had updated its briefings for the

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MAC-conducted Air Operations School to emphasize the role of aeromedical

evacuation as “an integral part of the overall MAC airlift process.”53

Roadman also addressed the CINC’s other major concerns in a positive vein.

With regard to the issue of obtaining accurate aeromedical evacuation requirements, the command surgeon assured General Johnson that these requirements

were not going to be driven by the number of service beds available. Instead, the

JCS was going to specify an evacuation policy for planning scenarios that would

involve combat and the generation of casualties and which were being developed

for the forthcoming Airlift Mobility Requirements Study and Defense Planning

Guidance. The policy would be used to determine the size of the aeromedical

evacuation force that MAC would be directed to plan for. Roadman asserted that

he expected overall aeromedical evacuation crew requirements to decrease.

The surgeon was able to report that both USAF headquarters and Air Force

Systems Command, which controlled SAM where Air Force flight nurses trained,

had concurred with the MAC vice commander’s proposal to study the feasibility

of establishing a MAC aeromedical evacuation schoolhouse. Roadman also noted

that the forthcoming JCEWG would discuss the baseline regulating and movement process and identify improvements to the aeromedical evacuation process

that required joint action.54

The mobility requirements study cited by Roadman was to update the CMMS,

which was published in 1981 and had sought to determine the proper mix of airlift,

sealift, and prepositioned materiel that the United States required for dealing with

tensions in the Middle East and the ongoing buildup of Warsaw Pact forces in

Europe. Subsequent analysis by the MAC staff of the requirements determined by

the CMMS, when it compared MAC’s existing and projected airlift capabilities,

identified shortfalls and made recommendations to remedy them. These recommendations were published in 1983 in the Master Airlift Plan.55 Similar concerns

resulted in assigning MAC’s C–9s from a dedicated aeromedical evacuation mission to a wartime mission in the mid-1980s in order to augment the Air Force.

The destruction of the Berlin Wall in 1989 created a different world. The new

challenges and potential military requirements that it presented raised the same

congressional concerns for efficiency and jointness which in 1987 had resulted in

USTRANSCOM’s creation. In the National Defense Authorization Act for FY

1991, Congress directed DoD to conduct a mobility requirements study that

would include a comprehensive review of all transportation requirements generated by the mobilization and deployment of U.S. forces for Operation Just Cause,

Desert Shield, and Desert Storm, and to project future mobility requirements to

meet U.S. national security needs in the new world environment of the late 1990s.

An interim report had been delivered to Congress in April 1991; the final three

volumes were scheduled for delivery beginning in January 1992.56

These reports included aeromedical evacuation requirements as an integral

part of total airlift requirements, and the study led to a greater integration of

aeromedical evacuation planning within the larger context of deliberate opera248

A History of Aeromedical Evacuation in the U.S. Air Force
tional planning. Combined with the ongoing USTRANSCOM initiative to secure

control of medical regulating (in which General Roadman played the key role)

and the increasing importance of General Johnson’s vision of quality in the MAC

culture, this period was something of a watershed in the emergence of a major role

for the command surgeon in readiness planning. The May 1993 publication of the

first in a series of strategic plans for the USTRANSCOM surgeon began with a

classic quality statement:

The vision of the TCSG [Office of the Transportation Command’s

Command Surgeon] is a commitment to leading change for continuous improvement of the global transportation system to provide timely, sensitive and safe patient transportation every time.57

The plan noted that, upon establishment in 1987, both the USTRANSCOM surgeon’s office and USTRANSCOM, per se, had trouble defining their missions. At the

time, the surgeon’s office had only one full-time and two dual-hatted members; by

the end of 1993 it would grow to thirteen full-time members and a fourteen-member

direct reporting unit, the ASMRO, with another twenty-four Category A reservists en

route—reservists assigned to fixed units, in this case, the ASMRO. With new global

responsibilities, ASMRO—soon to be the Global Patient Movement Requirements

Center (GPMRC)—needed to train these incoming reservists to deploy and establish

or augment medical regulating activities in the theaters.58

Based on new DoD directives that gave USTRANSCOM control of its components in peace and war and granted the command new authority over global

patient movement, the plan outlined for the command surgeon’s office a new,

clearer mission. To achieve these goals, it detailed a set of actions to be taken and

the milestones for their completion. The mission of the command surgeon’s office

included

serving as the DoD single manager for medical regulating;

exercising authority, direction, and control over ASMRO;

having authority to regulate patients into other theaters from

combat theaters;

having trained deployable medical regulators [the Category A

reservists];

establishing a centralized C2 system for global patient movement that integrated the separate theaters and processes and

offered both patient in-transit visibility and decentralized control to the supported CINCs;

reviewing and producing plans as well as assisting at conferences to develop time-phased force deployment data (TPFDD)

(schedules of personnel and equipment which had to be

deployed to support specific operational plans); and

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planning and participating in exercises to test medical readiness.59

The mission description emphasized that success would require “teamwork

and a directed effort toward strategic goals which everyone helps establish and

meet.” Such a statement seems a reflection of Johnson’s interest in pushing quality within his command and an indication of the success that the command surgeon, Roadman, experienced in establishing TQM principles as the framework for

planning by the surgeon general’s office.60 Roadman for perhaps the first time consistently systematized aeromedical evacuation planning and requirements on the

basis of rigorous analysis. As one of his staff members described his approach on

the staff, “If you couldn’t show him what value-added the system got from a proposal, you got turned away.”61

These were not isolated efforts. Gen. William Creech, TAC commander in the

late 1970s, used quality principles to reform his command, a task for which he

received extremely high praise from civilian management experts as well as from

Air Force Chief of Staff Gen. Merrill McPeak and from General Schwarzkopf’s

JFACC, General Horner. Both attributed much of the Air Force’s success in the

Persian Gulf War to Creech, and Horner wrote that he wanted everyone to know

of the monumental contribution Creech made to the success of the air campaign

by his “fresh ideas on how to organize and lead in the late seventies.”62 General

Johnson had similarly stressed to his senior staff that MAC focus on meeting the

customers’—the supported CINCs’—needs, which, as he sought to impress on his

command surgeon, meant primarily aeromedical evacuation support. In the two

years immediately preceding his assignment to command USTRANSCOM,

Johnson had served as thr CENTCOM deputy commander and Director of the

Joint Staff, where he had become interested in quality management.63 His imprint

of quality on AMC and then on USTRANSCOM is important because it provided an appropriate setting for General Roadman to pursue a TQM management

approach to the changing requirements for aeromedical evacuation. The development of aeromedical evacuation during General Roadman’s tenure as the dualhatted USTRANSCOM/AMC command surgeon occurred largely within the

TQM framework which he imposed on his staff after he arrived at

USTRANSCOM headquarters and which he emphasized during his subsequent

three years as surgeon general of the Air Force.64 Roadman was working to fix the

deficiencies in the patient movement system that Desert Storm had revealed, but

his work was complicated by changes that the Air Force chief of staff had imposed

somewhat unexpectedly on the Air Force’s basic organization which significantly

affected its aeromedical evacuation system.65

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General McPeak Reorganizes the Air Force

and the Aeromedical Evacuation System

In the autumn of 1991, General Johnson was diverted from the normal business of his dual commands by fundamental questions raised by the Air Force chief

of staff, General McPeak, about the commands’ structure and function. Johnson

became heavily involved in discussions with McPeak about reorganization proposals that McPeak had advanced to prepare his service for what he believed

would be the challenges to U.S. national security that the Air Force would face in

a post–Cold War world.66 McPeak believed that the existing Air Force structure by

functional organizations by major commands (MAJCOMs)—both the operational

and support commands—was no longer the structure with which the Air Force

could best meet future threats or budgetary circumstances. To better prepare the

Air Force for these challenges, McPeak proposed a radical reorganization of his

service, with substantial implications for how the Air Force would perform its

aeromedical evacuation responsibilities.

Within AMC, the major command to which the Air Force had assigned the

aeromedical evacuation mission, the initiatives that General Johnson had sponsored went forward under the leadership of General Roadman and his staffs in

USTRANSCOM and AMC. Not all would be realized, sometimes for surprising

reasons, but by June 1993 Johnson’s efforts to centralize intertheater medical regulation of patients under USTRANSCOM control were successful. Initially this

would have an unanticipated result, mitigating to a substantial degree the effects

of disruption on AMC’s touted seamless worldwide aeromedical evacuation system that General McPeak’s organizational changes were to create.67

General McPeak’s changes to the MAJCOM structure substantially impacted

AMC and MAC and affected the aeromedical evacuation mission. He proposed to

put all the shooters—fighters, bombers, and ICBMs—into an Air Combat

Command (ACC), together with the necessary supporting assets—reconnaissance

aircraft, C2 platforms, and tankers—to give the ACC commander control of everything he needed to fight effectively. MAC was to become the AMC and command

the bulk of the airlift resources and tankers used to refuel deploying fighters,

bombers, and strategic transport aircraft. AMC would also coordinate tanker

scheduling worldwide. Meanwhile, ACC could deploy its units overseas, giving a

theater commander well-integrated airpower assets to employ as a whole, as had

been the practice in World War II.68

McPeak extended the concept to the combat units themselves. During World

War II, AAF combat commanders controlled all functional organizations of whatever type were assigned to their base for support of their combat mission. In McPeak’s

formulation, the organizational principle was “one base, one boss.” After considerable discussion, some changes, and more than a bit of confusion at the new

MAJCOMs, the new Air Force organization went into effect on June 1, 1992.69A new

tanker-airlift control center (TACC) was created to provide centralized direction of

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Trends, Issues, and Bureaucracy
strategic airlift, including aircraft engaged in aeromedical evacuation and aerial refueling operations. The principal effect of this Air Force reorganization on MAC’s

aeromedical evacuation responsibilities was to fragment the once seamless, worldwide aeromedical evacuation system that AMC controlled centrally from Scott AFB.

In spite of the June changes, the core of the worldwide system remained

intact until September 1, 1992, when, regardless of personal attempts by Generals

Johnson and Roadman to convince General McPeak to the contrary, command of

the active duty C–9A units and associated AMESs in PACOM and USEUCOM

passed to the respective theater commanders.70 A parallel reassignment had

occurred on April 1, 1992, when the C–130s in the overseas theaters came under

the command of the theater commanders. On September 1 the tactical aeromedical evacuation mission remained under AMC, as did the CONUS-based active

duty C–130 units and their counterparts in the ARC.71

This arrangement was not to last. General Powell revised the unified command plan72 in spring 1993 and created the Atlantic Command, a new joint command with responsibility for operations in the United States to which the ACC

was assigned as the air component command. This reproduced in the CONUS for

the first time the structure of the overseas joint commands, and the new

USTRANSCOM/AMC commander, General Fogleman, proposed that it be replicated fully in the CONUS by giving the Atlantic Command’s air component control of CONUS-based theater airlift forces in the same way that such forces were

assigned to the theater air components of unified commands overseas.73 This

would permit AMC to focus all of its efforts on strategic airlift. Consequently,

CONUS-based C–130 units, both active duty and ARC, were reassigned from

AMC to ACC in July 1993 together with the tactical aeromedical evacuation mission.74 Thus were the tactically oriented, active duty 1st AMES at Pope AFB and

nearly 2,000 ANG and AFRES aeromedical evacuation personnel transferred to

the ACC.75

The chief of staff had earlier rejected the theater command structure for tactical airlift and aeromedical evacuation used during the Gulf War. He was strongly opposed to deploying a MAC general officer as COMALF again, or of accepting a new, somewhat broader role for him as commander of mobility forces. To

McPeak, the concept of deploying a general officer from outside the theater who

had command responsibilities in the chain of command went contrary to his one

base, one boss philosophy. Ultimately, the role of the former COMALF became

that of a staff officer on the JFACC’s staff carrying the title, director of mobility

forces (DIRMOBFOR), although not without misgivings on the part of some airlifters.76 As a result of this reorganization some active AMESs were redesignated.

The 1st AMES (Pope AFB) became the 23d; the 2d AMES (Ramstein AB)

became the 86th; the 9th AMES (Yokota AB) became the 374th; and the 57th

(Scott AFB) became the 375th.

This loss of administrative command of the overseas aeromedical evacuation

units did not extend to the domestic C–9A aeromedical evacuation system nor to

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the active duty strategic aeromedical evacuation units that remained under the

command and control of the new AMC, as did their counterparts in the ARC when

they were called to active duty. In effect, the formerly seamless worldwide

aeromedical evacuation system had been sundered into four aeromedical evacuation systems, and the AMC surgeon had been left with a somewhat ill-defined

responsibility for “proponency” of aeromedical evacuation throughout the Air

Force.77 With command and control limited to the domestic C–9A and the strategic aeromedical evacuation system, the surgeon possessed little direct capability

to compel adherence to his views on elements that composed proponency.

Generals Johnson and Roadman had argued to McPeak that “effective mission

execution resides in integration, in the continued drive to focus on the customer,

and to provide a seamless system. Function will inevitably follow structure—

fragment the structure and the function will soon follow.”78

With the theater AMESs now under COCOM of the theater commanders, the

issue for AMC was whether means other than exhortation would produce any effect.

Alarmed by the implications of a fragmented system for maintaining effective

aeromedical evacuation support of the combatant commanders, Roadman sought to

institutionalize multicommand mechanisms within which coordination of policy

and standards throughout the now separate aeromedical evacuations systems might

be effected. In October 1993, as the decentralization became effective, he established the Aeromedical Evacuation Readiness Committee (AERC) with five major

subcommittees tasked to develop specific programs on organization, training,

equipment, exercises, and inspections as a basis for ensuring that aeromedical evacuation system initiatives were standardized. To involve the commands with vested

interests in aeromedical evacuation (AMC, ACC, PACAF, USAFE, AFRES, and the

ANG), Roadman sought and received in January 1999 the approval of the AMC

commander to establish a senior body, the Aeromedical Evacuation Executive

Board (AEEB), which the AMC command surgeon would chair. Its ostensible function was to oversee the work of the AERC and established the strategic direction for

the global aeromedical evacuation system. At the same time, the facts that AMC

sponsored the board’s creation and that the AMC surgeon chaired it emphasized

AMC’s designated role as aeromedical evacuation system proponent.79

Although such a structure might function well in theory, its success would

depend on the absence of irreconcilable command interests and bureaucratic turf

concerns, a willingness to cooperate, and even compatibility among the key operatives. At least some of these problems were evident early on and were rooted in

differences between the principal aeromedical evacuation players, the AMC and

the ACC. Not until November 1995 was the AEEB to be convened, and then its

convocation was directed by the Medical Readiness Directorate of the USAF surgeon general’s office, rather than by the AMC command surgeon.80

In July 1994 General Roadman was reassigned from his dual positions at

USTRANSCOM/AMC to the Office of the Air Force Surgeon General, and his

successor as AMC command surgeon, Brig. Gen. Peter Hoffman, several months

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later sought to invigorate the structure Roadman had created. He began in October

1994 by suspending AERC activities pending agreement among the system players on a clear definition of their respective roles and responsibilities. To this end,

he hosted a four-day roles and responsibilities white-paper meeting at the end of

November 1994 when the attendees drafted a document that articulated their consensus on these key issues. They agreed to rename the AERC the Aeromedical

Evacuation Steering Group (AESG) and to rotate its chairmanship. On that basis,

ACC rather than the AMC surgeon would chair the AESG’s next meeting. This

never happened.81 AMC obviously felt that an ACC initiative to establish policy

for AECM qualification raised fundamental questions about what AMC’s responsibility for aeromedical evacuation proponency really meant. In late June, the

AMC surgeon requested clarification from Headquarters Air Force on which command had lead responsibility for aeromedical evacuation. Instead of a direct reply,

the director of Medical Readiness Doctrine and Planning in the surgeon general’s

office directed in late August that both the AESG and AEEB be convened and that

each be chaired by the Air Staff. The product of the AESG meeting in early

October was a new definition of proponency and the reaffirmation of the AMC

surgeon’s role as the Air Force agent for aeromedical evacuation system proponency, which it recommended to the AEEB for approval:

Headquarters Air Mobility Command (AMC) is the global

aeromedical evacuation (AE) advocate/proponent. As such, the

Command Surgeon (AMC/SG) reports to the Commander, Air

Mobility Command, and represents the USAF Surgeon General

in presenting or resolving issues that impact the entire AE community. AMC/SG provides leadership through arbitration,

coordination, and consensus building among committed system

elements. Works with the AE community and other agencies to

provide unity and facilitates the development of applicable joint

medical doctrine [emphasis in original].82

The AESG also described the AMC surgeon as maintaining an intertheater

aeromedical evacuation system in coordination with the CINCs, the ARC and

active duty component surgeons, and the MAJCOMs. The group went on to state

as existing fact what one more realistically would have to describe as its hope for

how the decentralized system would function. According to the AESG, “each of

the component parts’ functions are smoothly integrated, and the transfer of

patients within and between the component parts is accomplished without disruption to the patient or the supported CINC.”83 A more coldly realistic view of the

role assigned to his command by a senior AMC medical staff officer was that

“proponency is a new ‘new paradigm’ euphemism for responsibility without

authority” [emphases in original].84

When the aeromedical evacuation executive board met in late November

1995 it went beyond the recommendation of the steering group on the proper

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agent to “exercise” proponency, and it included the USTRANSCOM command

surgeon and the Air Force surgeon general’s Medical Readiness Directorate as

additional possibilities. Presumably with the retirement in late 1994 of General

McPeak as chief of staff in mind, the executive board also listed as an additional

option the recentralization of the aeromedical evacuation system.

This somewhat surprising recommendation came after some months of experience with the decentralized system that, at least in the eyes of many AMC medical officers, validated General Roadman’s concerns about the effect of General

McPeak’s decision. As one officer wrote with evident exasperation, function had

followed form, as the AMC surgeon had warned, and little possibility existed that

the now-fragmented global aeromedical evacuation system could establish anything like the former seamless worldwide system that AMC still believed to be

essential.85 The significantly greater importance in the role of the

USTRANSCOM/AMC command surgeon, a result of the USTRANSCOM commander’s successful resumption of the control over medical regulating, provided

coherence to the worldwide aeromedical evacuation system.86

Conclusion

The first joint doctrine on patient evacuation and movement, Joint Pub

4–02.2, Joint Tactics, Techniques, and Procedure for Patient Movement in Joint

Operations, was developed under the leadership of the AMC surgeon and published in 1996.87 It reflected the Gulf War experience and resolved a number of

interservice issues. It also clarified several issues that had generated friction in the

past, such as access to the combat zone for patient evacuation. Perhaps most

importantly, it codified USTRANSCOM’s responsibility as the single manager

for strategic and CONUS medical regulation of uniformed service patients. It used

the broader term, patient movement, defining it “as a system that involves the

coordinated use of intratheater and intertheater evacuation assets in support of

patient regulating decisions made by medical personnel.”88 It also described the

role of the GPMRC in the patient movement process: to provide medical regulating services including clinical validation, limited in-transit visibility, and requirements for intra- and intertheater aeromedical evacuations; to communicate patient

requirements to the service components executing the evacuations; and to coordinate intertheater missions through the AMC TACC and with Theater Patient

Movement Requirements Centers (TPMRCs). These centers were the result of

merging some of the functions of the JMRO and the AECC, and they communicated patient movement requirements between the AECC and the service components responsible for execution of the aeromedical evacuation mission.89

Some of the changes in the way the Air Force conducted its mission of providing aeromedical evacuation support to U.S. forces flowed directly from the

experiences of Desert Shield/Desert Storm. Other changes represented broader

attempts to increase the efficacy of evacuation support by clarifying the lines of

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Trends, Issues, and Bureaucracy
authority and responsibility and by improving the integration of the evacuation

units with the Air Force. Some changes reflected the possibilities that accompanied new technologies or the adoption of concepts that had been the subject of

lengthy discussion within the aeromedical evacuation community and made possible by the atmosphere of reform that General Roadman had created within

AMC. All would soon be tested by the new contingencies of the post–Gulf War

era, experiences that largely shaped the aeromedical evacuation system that followed.

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Chapter 11

EMERGENCE OF THE POST–GULF WAR

AEROMEDICAL EVACUATION SYSTEM:

NEW CONTINGENCIES

Aeromedical Evacuation in Transition:

Operation Restore Hope

Institutionalizing relevant portions of the Gulf experience was going to

require time as well as something more than the issuance of joint doctrine. The

deployment of U.S. forces to Somalia under CENTCOM command in late 1992

provides an early example of how the now-decentralized aeromedical evacuation

system might function and indicates how far the changes set in motion by AMC

had progressed. The Somalia intervention also provides an extremely useful

recent case study of the realities of performing the tactical aeromedical evacuation mission in an increasingly frequent type of contingency which involves the

participation of U.S. forces. Somalia illustrates the emerging environment in

which U.S. forces are used in coalitions not to defeat armed aggression but are

used to exercise peacekeeping and to achieve other objectives, such as nation

building. Actions that shaped and accentuated these trends in the evolution of

aeromedical evacuation lay not only in the Desert Shield/Desert Storm experience, but in Operation Just Cause as well.

On November 29, 1992, after extensive media exposure to the widespread

starvation and ongoing brutality in a civil war in Somalia, President Bush authorized the use of armed forces in Operation Restore Hope in support of UN

Security Council Resolution 794. Differing from a usual UN peacekeeping operation, the mission of the U.S. forces was to provide security as forces from other

UN members distributed food in central and southern Somalia.

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New Contingencies
As part of the necessary medical support of the U.S. forces, the 1st Tactical

AMES at Pope AFB was tasked to develop and implement an aeromedical evacuation system for both battle and nonbattle patients injured in the Somali AOR.

These patients were to be moved to third- and fourth-echelon MTFs located outside as well as within the AOR. The 1st AMES medical planners responded

quickly with CONOPLAN 1229, which they prepared at MacDill AFB, briefed

to CENTCOM and AMC staffs on December 4, 1992, and published five days

later.1

Presumably, this concept plan reflected relevant lessons from Desert

Shield/Desert Storm that Colonel Brannon, the 1611th AMES commander, had

recommended be integrated into aeromedical evacuation planning, procedures,

and processes. As the Somalia crisis unfolded, rather than validating the vision

embodied in his recommendations, the crisis tended to show just how difficult it

was to project future requirements into another context on the basis of the Persian

Gulf experience. In the event, the Bush administration’s decision to deploy U.S.

forces was made without much warning to the services, and it came at a time of

transition with respect to aeromedical evacuation policy and doctrine.2

The assistant chief of nursing of the 1st AMES, Maj. Farley Howell, was

ordered to the Somali capital, Mogadishu, via Rhein-Main AB with the primary

task of forming an aeromedical evacuation liaison cell within the air mobility element (AME). The AME was designed to perform the intratheater airlift that a

MAC ALCC had formerly provided. Usually collocated with the air component

commander’s air operations center, the AME complemented a tanker-airlift control element also deployed to Mogadishu, and it served as the theater extension of

AMC’s TACC at Scott AFB.3

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A C–141 on the ramp at Mogadishu, Somalia, during Operation Restore Hope in 1992.
This was a novel role that Howell was called upon to implement in the

absence of a specific charter or guidance.4 In the Gulf and in other, smaller contingencies, coordination between the aeromedical evacuation center and ALCC

was always present, and it was generally effected through physical means. During

Restore Hope, Howell was actually transferred to the operational control of the

director of the AME and, when “chopped” to the AME, became a part of that organization. In addition to his assignment to the AME, Howell was designated as the

aeromedical evacuation ADVON with the added responsibilities of conducting an

aeromedical evacuation predeploymment site survey and actually initiating

intertheater airlift operations. Aeromedical evacuation requirements were coordinated with the AME by an AECC initially located in Mogadishu.

This new concept necessitated separate organizations. Although the mission

was ostensibly a humanitarian effort, the chaotic situation in Mogadishu and elsewhere throughout the country presented different security requirements. The

major airfield available at Mogadishu was located on the southern, seaward side

of the city, and the location and anarchic situation in the capital mandated a degree

of security not generally required in the rear areas of the AOR during Desert

Shield/Desert Storm. A nurse historian termed Restore Hope “a humanitarian mission under hostile conditions.” More properly, it was an example of what is currently termed a military operation other than war.5

Pursuant to presidential authorization, the United States deployed more than

25,000 troops to Somalia; 13,000 troops from other UN member nations joined

them as a United Nations task force under U.S. command.6 More than 20,000 of

the U.S. troops were later withdrawn in accordance with the commitment of

newly elected President Bill Clinton’s administration to reduce the U.S. military

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New Contingencies

Marines patrol Mogadishu, Somalia, during Operation Restore Hope in 1992.
presence and turn over the operation to full UN control by May 1993. This new

UN-authorized presence was designated UNOSOM II and included some 4,000

U.S. troops, 2,000 of whom were logicians and only 1,300 were combat troops.

UNOSOM II was to operate under a more expansive UN resolution that sanctioned the use of force in accordance with Chapter VII of the UN Charter to

achieve the “consolidation, expansion, and maintenance of a secure environment

throughout Somalia” and to disarm the warring factions as the UN Secretary

General recommended.7

The tragic history of the failed UN efforts to pacify Somalia includes the

October 1993 deaths of eighteen U.S. special forces troopers during a failed

attempt to arrest Gen. Mohammed Aidid, leader of one of the principal warring

factions. A look at the theater aeromedical evacuation system established during

the Somali crisis indicates much about the readiness of the aeromedical evacuation system to operate in a joint context, as the after-action report by the commander of the 1st AMES reveals.8

Major Howell was delayed at Rhein-Main AB in Germany for some twelve

days pending the deployment of U.S. Marines to secure the Mogadishu airport

and other key points in the city. Accompanied only by Capt. Frank North, a flight

surgeon with no field experience, who joined him at McGuire AFB and who was

also assigned to the AME, Howell had neither the flight nurses, medical technicians, nor in-flight medical equipment to initiate aeromedical evacuation missions

on opportune airlift, should they be required. He also lacked equipment and additional personnel to provide the AME with an interim aeromedical evacuation

coordinating capability, pending the arrival of additional 1st AMES personnel.9

Fortunately, Howell’s former commander during Desert Shield/Desert Storm,

Col. Robert Brannon, was now commander of the 2d AMES stationed at RheinMain, and Brannon agreed to provide Howell with a limited amount of in-flight

medical equipment and to detach a flight nurse and two medical technicians from

his squadron to temporary duty in Mogadishu.10

Howell arrived in the Somali capital with his small medical retinue11 on

December 13. He immediately contacted Navy and Marine Corps medical representatives to acquaint them with the interim aeromedical evacuation capabilities.

He also conducted an aeromedical evacuation site survey. Pending arrival of an

Army evacuation hospital, the Navy amphibious assault ship USS Tripoli, visible

offshore from the Mogadishu airport, provided third-echelon medical capability in

the form of Navy surgeons, nurses, and sophisticated medical facilities. The

Tripoli had a medical regulator onboard in contact with the USEUCOM JMRO,

and Howell established communications with him using Marine Corps communications systems.

With these elements in hand, Howell directed an ad hoc aeromedical evacuation system until the AECC was established on December 19, when the main

body of deploying personnel from his squadron arrived. His system involved flying patients by helicopter from Mogadishu to the amphibious assault vessel,

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A History of Aeromedical Evacuation in the U.S. Air Force
where they were to be held after triage and further treatment to stabilize their condition. Their evacuation would be coordinated with the USTRANSCOM TACC

and USEUCOM JMRO, and they would be returned from the vessel by helicopter

to meet the departing opportune airlift identified for their evacuation.12

After U.S. forces dispersed to other locations in Somalia, they were supported by C–130s including C–130 Samaritan aeromedical evacuation missions similar to those flown within the AOR during Desert Shield/Desert Storm on a twiceweekly schedule.13 These missions picked up patients from battalion aid stations

in the Somali interior and generally carried them to Mombasa, Kenya, the C–130

bed-down location. Patients flown to Mombasa were generally ambulatory. They

remained overnight and were flown back to Somalia the next day for evacuation

from Mogadishu on a strategic aeromedical evacuation mission, usually a C–141,

although C–5s and KC–10 Extenders were also employed. Critical patients could

be flown directly to Mogadishu, especially after the Army’s 86th Evacuation

Hospital became operational in mid-January at the airport there.14

Medical capabilities at Mombasa were limited to squadron medical elements

and the flight surgeons who had deployed to support the aircrews assigned there.

Civilian hospitals in Kenya could be accessed, and occasionally, C–141 aeromedical evacuation missions were flown from Mombasa. Flight surgeon Lt. Col.

Courtney Scott based at Mombasa an extraordinary aeromedical evacuation mission recounted he had planned to move a badly injured serviceman to Germany.

His plan was to provide en route critical care as a desperate expedient, but the

patient died before the mission could be launched.15 As in previous conflicts, care

in the air would be provided to patients whose medical conditions dictated it, but

it was not a planned aspect of the aeromedical evacuation support to Operation

Restore Hope. The CONOPS developed by the 1st AMES assumed that austere

conditions existed in Somalia (and, for this reason, originating hospitals would be

required to prepare patients for movement) and that neither the MASF nor the

evacuating aircraft would have a physician routinely present. Only basic supportive care would be available to stable patients, a stable patient defined according

to AMC regulations as

one who, in the clinical judgment of the responsible

physician, can withstand a bed to bed evacuation of

6–24 hours without sustaining complications requiring invasive treatment of intervention beyond the

scope of general supportive care during evacuation.16

These aeromedical evacuation activities were based on the system established after the 1st AMES core personnel arrived in Mogadishu on December 19,

1992. Their mission was to establish a theater aeromedical evacuation system and

to include an AECC, an MASF, an AELT, and two aeromedical evacuation crews

drawn from the 1st. As with the AME, delay in moving these medical units into

the AOR in large part was, as in Desert Shield, the result of the higher priority that

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New Contingencies
the theater commander placed on the airlift of combat forces.17 Crew members

accompanying the main body were drawn from the ANG; one crew was qualified

on C–141s, and the other, on C–130s. An aeromedical evacuation operations team

(AEOT) and six aeromedical evacuation crews composed of volunteers from nine

ANG and AFRES units deployed at the same time to the Cairo West airfield,

which served as an aircraft refueling stop and an intermediate point in the

aeromedical evacuation system.

The AEOT mission was to provide en route support to intertheater aeromedical evacuations. This meant managing a pool of medical flight crews and generally facilitating the transport of patients from the AOR to hospitals in Germany.

As necessary, the AEOT dispatched flight crews to Mogadishu to support missions from the Somali capital or to replace the AECMs from Mogadishu who had

provided in-flight medical care to patients en route to hospitals in Germany. Both

flight and medical crews changed when the evacuating aircraft stopped to refuel

at Cairo West. Limitations on the length of time medical crews were allowed to

spend on duty and on the range of the C–141s mandated the stop at Cairo West.

Flight time for the C–141s from Mogadishu to Cairo West exceeded five hours,

exclusive of the time to refuel at Djibouti en route, which initially was standard

practice. The flight from Cairo West to Germany was an additional five hours.

Direct flights from Somalia to Germany required aerial refueling.18 As with the

AME, an AEOT had never before been deployed in conjunction with an AECC

during a contingency operation, which generated issues within the aeromedical

evacuation system. The AEOT was under the operational control of the TACC at

AMC, whereas the AECC was controlled by the DIRMOBFOR who had assumed

the role performed during Desert Shield/Desert Storm by the COMALF.19 Unlike

the AEOT, the AECC worked for the theater commander’s JFACC. This split in

the command and control of the aeromedical evacuation system (the product of

General McPeak’s desire to eliminate the presence in an AOR of a general officer

from outside the theater) contributed to the unresolved conflict between the

AEOT and the AECC over which controlled the strategic aeromedical evacuation

crews deployed at Cairo West and Mogadishu and, consequently, which had the

authority to assign crews to missions.20 As Brannon had discovered during Desert

Shield, an underlying factor was the self-perceived difference between tactical

and strategic medical flight crew members whose mission flexibility was initially

limited during the Persian Gulf War.21

While the initial deployment of troops and equipment to Somalia was underway, rather than interrupt the planned airlift flow in support of the deployment

originating at McGuire AFB, transiting Cairo West, and ending in Mogadishu, retrograde aeromedical evacuation missions from Somalia by C–141s or other strategic airlift generally delivered their patients to Cairo West. Patients reentering the

airlift stream transiting to McGuire from Cairo West came from an ATH deployed

there. The ATH at Cairo West held them until either opportune airlift or Colonel

Brannon’s C–9s from Germany became available to reload them and continue

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A History of Aeromedical Evacuation in the U.S. Air Force
their evacuation to USEUCOM hospitals.22 After the initial deployment was completed, C–141s evacuating patients from Somalia on retrograde missions generally refueled at Cairo West before continuing to Germany.23

In addition to these deployments, on December 19 a modified AELT

deployed to Rhein-Main AB. Consisting of three radio operators, it provided a

communications link between the evacuation elements in the AOR and Germany

until reliable telephone communications to the 2d AMES and the USEUCOM

JMRO could be established. Once this was achieved, AELT personnel redeployed

to the United States. When the aeromedical evacuation system was turned over to

ARC personnel in late March, the only active duty airman retained at Cairo West

was a radio operator from the 1st AMES.24

Communications for the aeromedical evacuation system to be deployed in

support of Restore Hope had been an immediate concern for the AMC surgeon.

He clearly viewed the Somali operation as an opportunity to field-test patient intransit visibility. On December 12, before the main body of aeromedical evacuation personnel from the 1st arrived, General Roadman informed the AMC commander that he had undertaken an initiative to deploy augmenting communications equipment to the AOR to provide a high-speed data capability for the standard voice-only Pacer Bounce HF radios that the aeromedical evacuation units

had taken to the field.25 This equipment included modems and personal computer

notebooks that the command surgeon said would permit three key objectives:

first, automate the aeromedical evacuation airlift request, the aeromedical evacuation aircraft arrival message, and the aircraft departure message, and messages

that track crews and equipment by location and type of asset; second, provide

robust and redundant communications to support data transfer between aeromedical evacuation forces and C2 centers; and third, provide supporting backup connectivity to the medical regulators at CENTCOM and USEUCOM. In the event,

HF communications proved to be generally unreliable; only the eventual deployment of a leased commercial International Maritime Satellite Network

(INMARSAT) terminal and access to the DoD tactical satellites provided communications that successfully linked the elements of the system on a reliable basis

during Restore Hope.26

Memories of the problems related to aeromedical evacuation during the Gulf

War were fresh enough to raise other concerns. One was the shortage of equipment needed to reconfigure C–141s for aeromedical missions. This deficiency had

occasionally been discovered during Desert Shield when aircraft away from their

home stations on tactical operations had suddenly been called upon to conduct

patient evacuation. Items such as stress cables, litter brackets, and oxygen manifolds were supposedly part of each aircraft’s standard onboard equipment at all

times, but even still-sealed kits occasionally were found to lack necessary items.

Similar shortages plagued the initial phase of Just Cause three years earlier.27 On

December 4, Headquarters Twenty-first Air Force at McGuire AFB, the CONUS

departure point for aircraft carrying troops and equipment to Somalia, directed a

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New Contingencies
message to AMC headquarters, the TACC, each of AMC’s strategic airlift wings,

AFRES headquarters, and the ANG Readiness Center requesting that each aircraft

be inspected before departing its home base to ensure that all equipment required

to reconfigure it for aeromedical evacuation was onboard.28

In Mogadishu, based on the need to simplify the coordination of patient transfers, the AECC was collocated with the AME on the grounds of the former U.S.

embassy, roughly three miles from the airfield and within the city proper. Also

positioned at the embassy, Alpha company of the Marine Corps’ 1st Medical

Battalion treated outpatients and inpatients who required stabilization before

being evacuated. After the first elements of the Army’s 86th Evacuation Hospital

arrived in Mogadishu in early January, the 86th became the de facto primary inpatient treatment facility in the theater. Located at Mogadishu IAP, the 86th was initially served by the MASF and four members of the AELT when patients from it,

Alpha company, or the Tripoli required aeromedical evacuation to Germany. To

facilitate the coordination of patient evacuation from the Tripoli, the two remaining members of the AELT from the 1st AMES were deployed to the ship. All told,

the 1st deployed 100 personnel to Somalia and three to Germany. The first

intertheater aeromedical evacuation mission was flown to Ramstein on December

16, 1992, with a patient load of one ambulatory and one litter patient supported

by the normal medical flight crew.29 As the 86th became fully operational during

January, the AECC began to evaluate the presence of an MASF at the airport as

redundant. The AECC reported to the TACC at Scott AFB that it might be possible to redeploy the squadron to Pope AFB by the middle of the month. Given the

desire to limit further U.S. involvement once the UN assumed responsibility,

returning the 1st AMES to Pope AFB and manning the system with ARC personnel seemed prudent in view of pending crises, notably in Yugoslavia.30

Personnel from the 1st had been evaluating potential air routes for evacuating

patients to the European MTFs. The relative absence of en route medical facilities

and the distance to Europe suggested that patients’ medical conditions could be

adversely affected. Given the initial requirement for aeromedical aircraft to transit

Djibouti for refueling, Major Howell and other personnel flew to that former

French colony in late December.31 Their purpose was to evaluate the suitability of

its medical facilities to receive U.S. patients if an aircraft experienced mechanical

difficulties and had to temporarily offload patients being evacuated to Cairo West.

Maj. John Felins had separately surveyed Addis Ababa in Ethiopia as another possible refueling point for the same reason. Although facilities at the French colony

proved to be quite acceptable, the lack of holding capabilities at Addis Ababa ruled

it out as a refueling point for retrograde evacuation missions from Mogadishu.32

The medical context of the deployment for which all this medical support had

been established changed sharply soon after the forces were in place. The predeployment casualty estimates for Restore Hope were 20 percent per week, which

CENTCOM medical planners had developed partially based on the casualty rate

experienced during the Persian Gulf War. In Somalia, U.S. casualties were expect264

A History of Aeromedical Evacuation in the U.S. Air Force
ed to result predominantly from extremely adverse epidemiological conditions

and psychological trauma induced by observing the effects of famine, particularly on Somali children. Only a very small component of these estimates was for

combat injuries incurred as a result of conflict with armed Somali civilians. The

CENTCOM estimates proved far too high, and with pressure building to minimize the U.S. presence, in late December the air component commander directed

that all elements review their requirements and redeploy nonessential personnel to

the United States.33

This was in keeping with the promise by the Bush administration that U.S.

forces would be withdrawn within a few months, and it also fit the perspectives

of the incoming Clinton administration which took office in January 1993. The

Clinton administration sought to use the Somali civil war as a model for reducing

unilateral U.S. deployments in favor of more aggressive UN actions to resolve

world crises. In the Clinton administration’s paradigm, the United States would

support a more aggressive UN-led multilateral approach that went beyond traditional peacekeeping but would provide neither the bulk of the forces nor, necessarily, the on-scene leadership.

As early as January 9, after the AECC had evaluated the continuing aeromedical evacuation requirement with the Air Force commander and the JTF, AMC,

and CENTCOM surgeons, AMC headquarters directed the AECC to plan for partially redeploying the 1st AMES to the United States not later than January 23.

This also fit the expectations of the AMC commander. Twenty-nine personnel

from the 1st left Mogadishu on January 28, returning with their equipment to the

CONUS. The continuing drawdown of U.S. forces was paralleled by further withdrawal of aeromedical evacuation elements and the reallocation within the AOR

of those that remained. In late February, more aeromedical evacuation personnel

were redeployed to the CONUS when the AECC moved from the U.S. embassy

to the Mogadishu IAP, where all aeromedical evacuation operations were consolidated. Two weeks later, on March 10, on Howell’s recommendation, the AECC

was transferred to Cairo West, hub of the airlift support for U.S. forces in Somalia,

and the AEOT and AECC merged.34 Reminiscent of Desert Shield, a provisional

unit, the 1610th Airlift Support Group (Provisional), was established to provide

an organizational structure for the ARC volunteers who were to man the system

after the UN assumed responsibility for Somalia. The force rotation policy was

originally envisioned as sixty days, but actual tour lengths varied.35

The AELT remaining at Mogadishu IAP after the AECC moved to Cairo West

was composed of a flight nurse, a Medical Service Corps officer, and two radio

operators who worked directly with the Army’s 86th Evacuation Hospital within

the airport compound.36 With one or two exceptions, the remaining active duty

personnel from the 1st AMES, including Major Howell, redeployed from the

AOR on March 19, after turning over the system to the ARC volunteers, who continued to operate it until U.S. forces withdrew as the UN disengaged from Somalia

in May 1994.37

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New Contingencies
In April 1993, after the ARC took over, the 86th relocated from Mogadishu

IAP to the embassy compound in the city. Redundant during the 86th’s presence

on the airfield, the MASF personnel were allocated other tasks or returned to the

CONUS, but the MASF tentage and equipment were retained as the basis for a

patient-holding capability. The CENTCOM surgeon requested the reactivation of

the MASF because of the 86th’s move, but this does not seem to have been done

on a permanent basis until Col. Robert Ditch, who had served on the CENTAF

surgeon’s staff during Desert Shield/Desert Storm in a unique assignment as an

advisor on aeromedical evacuation, requested it.38

Subsequently, until June, when vehicles began to be fired upon, patients

needing aeromedical evacuation were taken to the airport by ground transport for

evacuation in Air Force opportune airlift. After June, evacuees were moved by

medevac helicopter. In both cases, regularly scheduled, channel missions directed

by TACC evacuated patients from Mogadishu each Monday on a retrograde mission. When necessary, as when Pakistani troops suffered heavy casualties from an

unexpected attack by Somali gunmen in June 1993 or when the U.S. Rangers

were ambushed in October, the AELT coordinated emergency evacuation missions with the AECC, with a heads-up directly to the TACC. Later, the AECC was

once again moved, this time back to Mogadishu from Cairo West at the request of

Lt. Col. Loren Flossman, who arrived in the AOR in November 1993 to become

AECC chief.39

Restore Hope ended officially on May 4, 1993, when the United States turned

over command to the UN force commander for UNOSOM II, Lt. Gen. Cevik Bir,

a Turkish general. During the three months that the 1st AMES had operated the

aeromedical evacuation system, 266 U.S. patients had been moved intertheater—

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A History of Aeromedical Evacuation in the U.S. Air Force

USAF workers unload bags of flour during Operation Restore Hope.
106 on litters and 160 ambulatory—and 38 had been moved intratheater—19 on

litters and 19 ambulatory. From May to December 1993, during the period of UN

control, the Air Force aeromedical evacuation system carried 476 U.S. patients

and moved 123 coalition patients intratheater and 167 coalition patients intertheater for UNOSOM. Army medevac elements moved 1,351 U.S. patients intratheater and 346 coalition patients for UNOSOM. The Air Force transported 15

Somalis, and the U.S. Army moved 153. For the entire period of U.S. involvement, including humanitarian airlift before the initiation of Restore Hope and during the succeeding UNOSOM II, for which U.S. support was codenamed

Operation Continued Hope, some 850 patients were aeromedically evacuated on

125 missions.40

What does an analysis of these operations reveal about how much aeromedical evacuation had changed since the Gulf War experience? Primarily, the Somali

crisis revealed the aeromedical evacuation system to be still in transition.

Command and control of aeromedical evacuation forces in the AOR had been

modified in accordance with General McPeak’s vision of a clearer line of authority. A DIRMOBFOR with reduced command authority replaced the COMALF.

This appeared to work reasonably smoothly during Restore Hope, but as Desert

Shield/Desert Storm showed, the personal chemistry among the principals contributed positively to make the new organization work. Because AMC deployed

the strategic and tactical airlift aircraft and tankers that were the only Air Force

aircraft directly supporting Restore Hope, the commander of AMC’s 437th Airlift

Wing based at Charleston AFB, Brig. Gen. Thomas Mikolacjik, was designated

the joint Air Force commander. To be the DIRMOBFOR he personally selected

Col. Walter Evans, another airlifter and an old friend who commanded AMC’s

1701st Mobility Squadron at McGuire. Rounding out the aeromedical evacuation

command structure, the AECC OIC served as director of aeromedical evacuation

forces.41

Prior personal relationships factored significantly in the smooth operation of

the aeromedical evacuation system, which continued to function with ARC personnel directing it during the remaining months of the UN’s Somalia operation.

Colonel Flossman, commander of the AFRES 142d AMES based at Wilmington,

Delaware, who deployed to direct the AECC in late 1993, had worked as Colonel

Brannon’s chief of staff during Desert Storm. Capt. Susan Konczal, who directed

the AELT in Mogadishu from June 16, 1993, until early December, overlapping

Colonel Flossman’s tenure as AECC chief, had served as Brannon’s administrative chief in the 1611th AMES during the Gulf War. A significant number of other

ARC personnel in charge of aeromedical evacuation system elements throughout

the UN operation in Somalia had served together less than two years earlier in

Desert Shield/Desert Storm.42 Notably, although not a physician, Colonel Ditch

served as the CMO for the UN Somalia operation throughout UNOSOM II. As

CMO he had responsibility for, among other things, the coalition intertheater

aeromedical evacuation as well as the intratheater medevac of patients. Although

267

New Contingencies
intratheater medevac was usually performed in joint operations by the respective

U.S. service, Ditch had to deal with national contingents in UNOSOM II to secure

the required capability.43

Restore Hope does not appear to have stretched AMC’s resources for

aeromedical evacuation—after-action reports suggest that the aeromedical evacuation system was run on a shoestring until the Ranger episode in October—but

this was not true of AMC’s airlift capabilities. These were taxed so severely during the deployment that AMC headquarters twice had to raise the maximum number of hours that AMC flight crews were allowed to fly each month and to

increase the maximum crew duty day from sixteen to eighteen hours.44 Looming

also was an emerging crisis in Yugoslavia. The operation of the aeromedical evacuation system during Restore Hope revealed a number of concerns, which included several that were seen during the Persian Gulf War, but a new one arose with

the potential to have major implications.

Whether the new organizational arrangements in the aeromedical evacuation

system would function as well if the joint Air Force commander in a future, more

serious contingency had a different operational background remained to be seen.

The distribution of authority between the AECC and AEOT in the aeromedical

system would obviously need to be clarified if the usefulness of the AEOT was to

be preserved, or at least further tested and validated. Because both elements were

controlled by AMC, doctrinal change provided a straightforward remedy.45 The

value of including an aeromedical evacuation cell in the other new organizational element, the AME, also needed to be evaluated, as did the contribution of the

AME itself to increasing the effectiveness of the intratheater airlift.

A different kind of organizational situation that emerged during UNOSOM II

appeared to have doctrinal and resource implications for aeromedical evacuation

in future contingencies involving UN or other supranational authorities. This was

the unofficial exercise of a kind of tactical command over the elements of the U.S.

TAES in Mogadishu by a UN official, in this case, Colonel Ditch.46

Although not formally under UN control, USAF aeromedical evacuation personnel had consistently responded voluntarily to Ditch’s requests for both intraand intertheater patient evacuation of non-U.S. coalition personnel. This support

lay outside the formal responsibility of the United States and included providing

medical flight crews to act as AECMs on two Italian helicopters that stood alert

during or prior to mass casualty incidents, and on a C–141 that evacuated wounded Pakistanis to Islamabad after the June 1992 attack on a UN contingent by

Aidid’s forces.47

AECMs published a UNOSOM medevac configurations/operations guide

outlining how to configure and use any type of fixed- or rotary-wing aircraft that

UNOSOM II had available for use in medical evacuation. USAF evacuation personnel also voluntarily established training teams to prepare personnel of the

Indian medical contingent to perform in-flight medical duties in an effort to assist

the CMO when too few trained medical flight crews were available. U.S. Army

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A History of Aeromedical Evacuation in the U.S. Air Force
medevac helicopter personnel also provided intratheater patient movement at the

CMO’s request.48 The UN never provided medical flight crews to the UNOSOM

operations, which forced Ditch to rely on aeromedical capability brought to

Somalia by the national contingents. Though several nations provided medical

personnel, their numbers were very small, and the bulk of patient movement

responsibility fell upon the United States.49 Ditch estimated that USAF and U.S.

Army medical crews flew 70 percent of UNOSOM II intra- and intertheater missions. Other nations evacuated patients from their own deployed contingents, but

only U.S. aeromedical forces were willing to accept patients from other nations.50

When reading the UN CMO’s after-action report, it becomes readily apparent that the issue of providing aeromedical evacuation in support of peacekeeping

operations deserves serious consideration in light of this somewhat ambiguous

precedent. UN headquarters had no plans for providing intra- or intertheater

aeromedical evacuation capability before it initiated UNOSOM II, and apparently no substantive medical planning had been done at all. UN headquarters asked

the United States to provide the theater surgeon/medical director (referred to in

UN parlance as the CMO), and Ditch volunteered in response to an Air Force

advertisement. He expected to be a medical planner for a military theater surgeon;

instead he found he was the CMO and had not only to establish a staff but also to

design, develop, and manage a UNOSOM II health care delivery system.51

What made the Somalia experience potentially more salient was the fact that,

beginning in late 1991 and continuing throughout 1992, the CJCS, General

Powell, had given impetus to high-level studies examining just what role U.S.

forces might play in UN peace operations.52 Medical aspects of such operations

were not considered. Ditch was quite direct in his recommendations regarding

aeromedical evacuation in his end-of-tour report. He pointed to the need for

“responsive aeromedical evacuation coverage” for future operations like UNOSOM II to include aircraft, trained and equipped aeromedical evacuation crews,

and “good” command, control, and communications procedures and equipment.

Operation Restore Hope marked the first time aeromedical evacuation support

was required for U.S. troops directly engaged in peace operations under the auspices of international institutions like the UN or NATO, a situation likely to be

repeated.53

Operation Restore Hope also marked the first test of USTRANSCOM’s new

authority to regulate and coordinate airlift for strategic aeromedical evacuation

through the aeromedical evacuation cell in the TACC. TACC controlled the airlift,

including allocation for patient movement, but the USEUCOM JMRO still regulated patients evacuated to Germany because the GPMRC had not yet been established. (Only in June 1994 did the GPMRC become operational at Scott AFB.54) The

AEOT–AECC friction was an issue with implications for patient movements within the TAES that obviously needed resolution, but considering strategic aeromedical

evacuation, AMC’s medical regulation of patients originating in Somalia through

hospitals in USEUCOM to the CONUS appears to have worked well.

269

New Contingencies
The physical presence of aeromedical evacuation personnel in TACC greatly

facilitated the smooth assignment of patient evacuation missions. This was true

even though Restore Hope initially experienced a few problems when the TACC

did not receive timely flight-following information. According to observers, this

made TACC unaware on several occasions that there was actually a C–141 on the

ground at Mogadishu which the AECC had proposed to use for aeromedical evacuation.55

The presence of the aeromedical evacuation cell in the TACC proved particularly valuable during UNOSOM II. After the AECC moved to Cairo West at the

end of March 1993, primary communications among elements in the aeromedical

evacuation system became dependent, at least formally, on the Pacer Bounce HF

radios. The sometimes less-than-responsive communications between the AECC

at Cairo West and the AELT in Mogadishu, combined with the high data demands

of the peacetime system, helped inject delays into the process of securing the

evacuation of patients from the Somali capital. However, when the severely

injured Ranger casualties needed emergency medical evacuation after their illfated attempt to seize General Aidid in October 1993, the OIC directing the AELT

at Mogadishu IAP was able to alert Col. Sarah Wright directly from Mogadishu

using the Defense Switched Network (DSN). Colonel Wright, the first flight nurse

to head the aeromedical evacuation cell in the TACC, had been personally selected by General Roadman to fill this position. Even though Colonel Chester, the 1st

AMES commander, had encountered difficulties with the DSN during Restore

Hope, Colonel Wright has indicated that communications with Mogadishu were

always better than they were with Cairo West.57 Wright’s awareness of the situation at Mogadishu facilitated the rapidity with which the Ranger casualties were

evacuated. Fortuitously, the regularly scheduled Monday C–141 aeromedical

evacuation flight was already scheduled for October 4, and it was quickly joined

by other aircraft fed into the evacuation flow.57

Although medical regulating at least nominally directed by USTRANSCOM

generally functioned well during the Somali crisis, there was broad dissatisfaction

with the communications that supported the information flow needed to move

patients. Contemporary reports from the field, after-action reports, and interviews

with participants involved with aeromedical evacuation operations during each

phase of U.S. involvement in Somalia identify deficiencies in the communications

systems required for timely patient movement. The problem was less an inability

to communicate point-to-point between some nodes in the system, such as

between the AELT in Mogadishu and the AECC at Cairo West, or between the

AECC and the TACC; it was inefficiency inherent in the system as a whole that

arose from the lack of a totally reliable secure communications net connecting all

nodes of the deployed evacuation system with the nodes controlling regulating

and the C2 system for aircraft providing the actual patient lift.

Even the DSN, the standard worldwide DoD communications system, was

inadequate at times. Colonel Chester, the 1st AMES commander, noted in his

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A History of Aeromedical Evacuation in the U.S. Air Force
after-action report that the DSN had proved at best unreliable during the operation, and he clearly favored INMARSAT, its major advantage being its ability to

transmit data by facsimile to any receiving machine worldwide and to provide the

TAES with a direct link to any CONUS-based aeromedical evacuation component

having a telephone line. However, INMARSAT terminals belonged to the Air

Force Combat Camera Team in Mogadishu, and INMARSAT is a commercial

system that the Air Force had to lease at considerable expense. Chester reported

that during several critical weeks of the operation, INMARSAT was the only

available means to communicate other than by the tactical UHF satellite (SATCOM) communications system.58

SATCOM terminals had been deployed to the AOR with the 1st AMES and

placed at key nodes in the aeromedical evacuation system to provide redundancy

and enhanced reliability. In light of Colonel Chester’s comment, when the 1st

AMES redeployed to Pope AFB in late March, the UHF SATCOM terminals

returned with him to the CONUS. Because SATCOM was not standardized for

aeromedical evacuation communications, ARC aeromedical evacuation units had

no terminals and relied instead on the Pacer Bounce HF radios for communications. Consequently, neither the AELT nor the MASF at Mogadishu IAP was

equipped during UNOSOM II with the terminals whose reliability the 1st AMES

commander had lauded.59

In Somalia, AMC operations also marked the first significant use of KC–135

and KC–10 tanker aircraft for retrograde strategic aeromedical evacuation normally performed by C–141s, or occasionally by a C–5. The C–141s developed structural problems that restricted their performance, grounding them for required

inspections and forcing other aircraft to be considered for strategic evacuation.60 The

KC–10 was utilized for patient evacuation, but not without some hesitation on the

part of the aeromedical personnel in the AOR. On January 28, 1992, two critical litter patients were evacuated for the first time on a KC–10 from Mogadishu to

Germany. The decision to effect their evacuation was three hours in the making

because the evacuation personnel were unfamiliar with the equipment and procedures for this aircraft. These two patients arrived in Germany an estimated twentyfour hours earlier than they would have if another form of airlift had been used.

Success in this mission led AMC’s Air Mobility Warfare Center to recommend that all aeromedical evacuation crews be given immediate familiarization

and emergency egress training. Such classes were in fact held at Cairo West, and

several experiments on loading litter patients on C–5s were conducted there.61 As

a result, one of the functions of the TACC aeromedical evacuation cell became to

validate that the type of aircraft available to provide the required patient lift was

suitable in terms of the patient’s medical condition. Ambulatory patients could be

carried safely on virtually any cargo aircraft, but litter patients had to be evaluated against the type of airlift available.62

Other aspects of the aeromedical evacuation system were more in accord with

pre–Persian Gulf War policies. The AMC CONOPS for Operation Restore Hope

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New Contingencies
affirmed the traditional Air Force prohibition against carrying other than stable

patients. In contrast to the practice initiated during Desert Shield/Desert Storm of

routinely putting flight surgeons on aeromedical evacuation missions, the

CONOPS specifically ruled out this practice. The policy of not providing Air Force

physicians to augment the regular flight nurse/medical technician team on standard

evacuation missions was formally observed throughout Operation Continue Hope.

In a number of emergencies, attendants did accompany patients whose stability

was questionable. As in Operation Just Cause, when for the first time stabilized

rather than fully stable patients were deliberately aeromedically evacuated, the

evacuation system was adapted to the need at the moment. One such adaptation

was to reduce the size of the medical flight crew from the standard two flight nurses and three medical technicians to one nurse and one or two technicians. This

practice was followed during most of the period when the routine Monday flights

from Mogadishu were generally adequate.63 The governing medical directives

issued by Colonel Ditch for UN forces actually identified a theater evacuation policy. In May he specified a policy of seven days, and at the end of the year he

extended it to fifteen days. These were effectively only recommendations because

the nations providing the force contingents were formally responsible for evacuating their own patients. The combat support hospitals in Mogadishu that the United

States successively deployed during UNOSOM II to support its logisticians and the

residual combat force—the quick reaction force—normally held patients for a

maximum of seventy-two hours. This was obviously a flexible policy because,

unless a patient’s condition dictated a more critical need, aeromedical evacuation

was conducted on regular Monday missions from Mogadishu.64

When medical attendants were needed to accompany less than fully stable

patients, the originating MTF was tasked to provide them, and medical personnel

were drawn from the Army hospital in Mogadishu on several occasions for this

purpose. Because the hospital staff was relatively small, this Air Force policy,

which did not please the Army, was unsustainable when casualty numbers were

large, and attendants were found where possible. For example, an Air Force flight

surgeon was dispatched as an attendant on the initial C–141 that evacuated casualties of the fight between the Rangers and Somalis on October 3, even though he

had just arrived to relieve his predecessor in the MASF. Also, a Navy flight surgeon based in Mombasa served as the attendant on the second flight with Ranger

patients that departed in midafternoon on October 5.65 In the aftermath, the director of aeromedical evacuation forces, Lt. Col. Eileen Hadbavny, requested that

additional flight surgeons be dispatched to Mogadishu to preclude having to call

upon the Army’s 46th Combat Support Hospital in another mass casualty situation

to provide attendants for evacuees on ventilators or those who might otherwise

require intervention during the nonstop flight to Ramstein.66

Some issues that first appeared in Desert Shield also appeared during the initial days of Operation Restore Hope. Colonel Chester noted in his after-action

report that Army physicians who were deployed to locations in the Somali hinter272

A History of Aeromedical Evacuation in the U.S. Air Force
land were not initially aware how to obtain evacuation support. As they had discovered in the Saudi desert, aeromedical personnel in Somalia found that maintaining vehicles and aerospace ground equipment (AGE), such as portable power

units, was a continuing problem during the 1st’s ninety-day deployment. It was

often difficult to obtain maintenance support, and even AGE and communications

technicians who were deployed with the AECC to enhance maintenance capability were hampered by a lack of tools, technical data, and spare parts. In an echo

of Brannon’s after-action report on Desert Shield/Desert Storm, Chester also

noted that the AGE equipment the aeromedical evacuation personnel brought to

Somalia was dissimilar from that of the host units, which consequently could provide little or no assistance. Difficulties were also noted with the volume of patient

information that the aeromedical evacuation system managers required. It was a

volume that, in the view of the 1st AMES commander, constituted “an unnecessary burden to aeromedical evacuation elements operating under austere conditions and often very tight time constraints,” especially because the same data were

available at the USEUCOM JMRO.67

During Operation Continue Hope, another undesirable element characteristic

of Desert Shield/Desert Storm appeared. Pallets of medical supplies arrived at

Cairo West without inventory lists; some were stored in the open under deteriorating covers and were subject to the desert sun. Other equipment found to be serviceable required recalibration before it could be used. While the ATH at Cairo

West could recalibrate certain equipment, other ATHs required equipment that

was only available—but not accessible as it turned out—in Turkey. Thus, the

equipment was effectively useless.68

A unique case in Somalia involving the intersection of Special Operations

Command (SOCOM) operations with the Air Force aeromedical evacuation system had implications for the future. In a situation suggestive of Operation Just

Cause, the MASF at Mogadishu IAP was co-opted as a JCCP by the joint special

operations task force (JSOTF) of Rangers and Delta Force soldiers sent to seize

the Somali warlord Mohammed Aidid. In late August 1993, shortly after the

arrival of Army Rangers and other personnel from Fort Bragg, the JSOTF surgeon, Lt. Col. Philip Volpe, approached Major Konczal, the AELT OIC at

Mogadishu IAP, with a contingent request for medical support.69 Volpe asked

Konczal, a Medical Service Corps officer who had herself recently arrived for a

voluntary tour of duty from her reserve unit, to allow the MASF to function as a

joint casualty collection point if casualties were suffered during the operation for

which the SOCOM forces had been dispatched.70 The MASF tent was located just

inside the airport entrance and was staffed with Air Force flight nurses and medical technicians drawn from the ARC, a number of whom had substantial backgrounds in ATLS and advanced cardiac life support. Two active duty personnel,

Dr. John McNamara, a flight surgeon with a background as an Army special

forces doctor, and an independent medical technician, Sgt. Bill Thomaston, with

experience as a surgical technician, were also assigned to the MASF.71

273

New Contingencies
The MASF was also only approximately 200 yards from the JSOTF command post located in the hangar in which the 400 or so Rangers and Delta Force

troopers were billeted. The living compound for the Air Force medical personnel

was located nearby, on the other side of the MASF from the SOTF hangar.

McNamara’s prior service as a special forces medic was undoubtedly also a factor in Volpe’s request (he knew McNamara well), but most important to the surgeon for the Ranger task force, Maj. Rob Marsh, was that the MASF was located

less than a mile from where the attempted abduction of Mohammed Aidid would

occur.72

Marsh and Volpe divided the responsibility for the medical support of the

Rangers: Marsh had tactical responsibility for providing first aid and immediate

emergency treatment by forward medics, evacuating casualties to the casualty collection point (the MASF tent), and triage and emergency treatment; Volpe was

responsible for the medevac of patients from the MASF/JCCP (or later the

Pakistani-held stadium) to the 46th Combat Support Hospital and for strategic

evacuation from Somalia to Germany or to the CONUS. In the medical hierarchy,

Volpe was Marsh’s superior.73

The JSOTF surgeon predicted to Major Konczal that it might be necessary to

use the MASF as a JCCP “only if a helicopter went down,” an event he indicated

he believed would be relatively unlikely.74 Well aware of the limited medical capabilities available in the immediate area and responsive to the pressure, implicit

externally and generated internally by her wish to be supportive should wounded

Americans might require medical help, the AELT OIC agreed, without consulting

her chain of command.75 Major Marsh, the Ranger task force surgeon, then discussed with the MASF OIC, lst Lt. Kay Rast, ANG, how he wanted the casualty

flow established, among other clinical details of the MASF’s new role.76 In anticipation, McNamara and the MASF staff cadged equipment wherever they could,

in preparation for treating patients suffering trauma.77 Meanwhile, the Rangers

trained on the airfield and conducted practice sorties into Mogadishu, in one of

which they were able to seize of Osman Atto, an important Aidid lieutenant.78

Several joint drills were set up to prepare the personnel scheduled to be involved

in the JCCP as they waited to launch the mission to seize Aidid. During these

drills a series of minor casualties occurred that served to provide realistic training.

In a later description of this joint training, Marsh said willing the cooperation and

clinical skill of Air Force personnel at the airport were instrumental in the successful treatment of the Ranger and Delta Force casualties, particularly for the low

death rate among them.79 He volunteered that the role of the Air Force personnel

“has not been fully appreciated...for how important they were to the success of our

operation.”80

Although the Rangers81 operated under a purely U.S. command structure,

Colonel Volpe, as JSOTF surgeon, also established a good but wholly unofficial

working relationship with the UNOSOM II CMO, Colonel Ditch. It seems clear

that Volpe was seeking to ensure that all available medical support could be mar274

A History of Aeromedical Evacuation in the U.S. Air Force
275

New Contingencies

shaled in support of the Rangers and Delta Force personnel if the secret operation

went awry. Although he did not tell Ditch what their mission was, Volpe agreed to

let Ditch know when it was about to begin by passing a code word by radio. For

this purpose, Ditch provided Volpe with a handheld radio with three channels

unique to himself.82 Although the MASF had already been used for such a purpose

on a number of occasions after the assault on the Pakistanis in June, the out-of-doctrine use of the MASF by SOCOM forces was now a commitment without involving any Air Force member, other than a relatively junior Air Force medical officer,

in the decision.83 The role that Air Force aeromedical evacuation personnel played

in providing medical support to the Rangers undoubtedly contributed to muting if

not eliminating potential doctrinal concerns. Each aeromedical evacuation staff

member received a Joint Forces Commendation Medal personally from the JSOTF

commander, Gen. William F Garrison, before the Rangers left Mogadishu.84

By contrast, in the planning for Operation Just Cause, the 1989 mission in

Panama in late 1989 to seize Manuel Noriega, the role of the Air Force aeromedical evacuation system had been carefully defined beforehand. Planning had

occurred over an extended period and involved the then-commander of the 1st

AMES, Colonel Brannon, the USSOUTHCOM senior medical staff officer, Col.

Felix Meyer (coincidentally, the 1st’s former commander), and representatives of

the SOCOM medical units that spearheaded the invasion. Their planning had been

extremely close hold, and the operation had been sanctioned at the highest levels

of the U.S. government.

The Rangers began their mission into Mogadishu at midafternoon on Sunday,

October 3, and confronted trouble almost immediately. Two Blackhawk helicopters were shot down, and Rangers were soon pinned down, under siege, where

they would remain into the early morning.85 The first Ranger casualties, many

badly wounded, began to arrive back at the airfield within two hours. There, flight

nurses and medical technicians performed triage on the wounded in the open, near

the MASF. Patients requiring emergency surgery were moved inside to what in

effect had become a battalion aid station, a second-echelon MTF where two treatment stations had been established. One station was manned by Colonel

McNamara, the Air Force flight surgeon. He was assisted by the flight nurse who

was the MASF OIC, Lt. Col. Sylvia Johnson, and the independent medical technician, TSgt. Bill Thomaston. The other station was manned by two Army medical officers from the JSOTF, provided by Dr. Marsh. One was a physician’s assistant, and the other, Lt. Col. Adams, was the Army flight surgeon for the 160th

Special Operations Aviation detachment. Their assistant was an Air Force flight

nurse assigned to the MASF. While the two Army medical officers were periodically called out for activities with their unit, McNamara and other Air Force

aeromedical evacuation personnel continued work with the casualties until the

flow slowed and essentially ceased around eleven in the evening.86

After receiving care at the MASF/JCCP, patients were flown by helicopter

from Mogadishu IAP to the combat support hospital at the embassy compound for
further care. When the requested patient airlift became available soon after daylight the next day, the men were returned to the airfield by helicopter to be

aeromedically evacuated by C–141s. During the initial influx of casualties, Dr.

Marsh, the Ranger force surgeon, moved between the MASF and the JSOTF operations center at the airport, coordinating the medical effort and keeping the MASF

personnel informed of the situation as it changed. He later flew to the stadium

where the survivors of those pinned down in the city were taken. Most of those

rescued early on Monday were taken some five miles away to the Pakistani base

in the city and were later medically evacuated to the combat support hospital.

Some were brought to the airport where they were triaged and treated in the

MASF/JCCP.87 Of some 110 casualties suffered during the failed attempt to capture Aidid, 75 percent underwent triage by Air Force personnel at the airport and

then received emergency surgery or other treatment in the MASF/JCCP.88

Before being evacuated from Mogadishu on Monday, patients were

processed for aeromedical evacuation. Because so many were arriving by medevac from the 46th Combat Support Hospital, both the MASF and another nearby

building were used. To speed the loading of the aircraft, a few men were taken

directly to the aircraft if they appeared to be sufficiently stable. All had been validated for evacuation by air by the flight surgeon, Dr. McNamara, and by the flight

clinical coordinator, Capt. Susan Martello, assistant OIC of the MASF, both of

whom had been flown by helicopter to the 46th Combat Support Hospital early

that morning.89 The TACC and the airlift system proved equally responsive to the

challenge. The first C–141 arrived at Mogadishu IAP to evacuate the wounded at

daybreak, roughly fourteen hours after the first casualties began to arrive there.90

A C–5 carrying medical personnel and equipment drawn from the ATH at Cairo

276

A History of Aeromedical Evacuation in the U.S. Air Force

Casualties being evacuated from a downed Blackhawk in October, 1993.
West that arrived several hours after the C–141 was directed not to land because

of sporadic ground fire. It returned to Cairo West, leaving patient care essentially

to those already on the ground in Mogadishu.91

Accompanied by Lt. Col. Lewis Bartles, a flight surgeon who had just arrived

on the C–141, twenty-three litter and six ambulatory patients were flown directly

to Ramstein AB. The nine-hour flight without a refueling stop at Cairo West was

made after it was agreed that the Ranger casualties required treatment beyond the

capabilities of the Cairo West ATH.92 The 46th Combat Support Hospital had medically regulated the evacuees, and AELT and MASF personnel at Mogadishu airport made parallel efforts to provide information to Cairo West that could be

relayed to the USEUCOM JMRO. Confusion at Ramstein and at the Landstuhl

Army hospital about the first load of Ranger casualties occurred because sparse

patient information was passed to Germany. The information seems to have been

generated in a contingency mode, in which only the number of patients was transmitted and neither a name nor the patient’s specific medical condition was supplied. Whatever the reason, the lack of such information certainly accorded with

the SOCOM’s general reluctance to identify its people publicly.93

Curiously, neither of two quite detailed popular accounts of the events of that

that day mentions any contributions by the Air Force aeromedical evacuation personnel at Mogadishu.94 One published in 1994 and coauthored by a civilian doctor treats the presence of Air Force flight nurses dismissively (and erroneously) in

a brief paragraph: “The Air Force had some reserve nurses rotating through their

annual training assignments. They were spending much of their time comforting

the less severely wounded.”95

The unexpected role that the Mogadishu MASF played in the Ranger episode

generated discussion within the aeromedical evacuation community at AMC, but

it apparently had little formal effect on the ongoing evolution of the system.96 It is

notable that two flight surgeons at Mogadishu, with the concurrence of the JSOTF

surgeon, Dr. Volpe, and the support of the director of aeromedical evacuation

Forces, Colonel Hadbavny, sought to regularize the role of the MASF as a JCCP

by requesting deployment of additional physicians trained in acute care.97

Although intended to address the possibility of another mass casualty situation, this deviation from AMC aeromedical evacuation policy and the expanded

MASF role raised questions regarding applicability to future contingencies.

Interestingly, the 44th Medical Brigade commander during the Gulf War recalled

that he thought the evacuation system in the desert would function similarly to

what he had experienced at Howard AFB in Just Cause98 when SOCOM medical

personnel and Air Force aeromedical evacuation personnel had essentially been

integrated to provide triage and emergency medical treatment.

In both the Panama and the Mogadishu situations, stabilized rather than clinically stable patients were quickly transported to fourth-echelon MTFs by

aeromedical evacuation. The Mogadishu episode may well have been the precedent for the presence of SOCOM representatives in the TACC that Colonel Wright

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New Contingencies
reports during her tenure in TACC, when AMC provided airlift support to special

operations task forces. Certainly, the unplanned (at least by the Air Force) integration of Air Force medical capability in the form of the MASF and the assignment of aeromedical evacuation personnel into the Mogadishu events of October

1993 presaged the increasing jointness of medical support provided to deployed

U.S. forces. This was to be more formally structured into later contingencies, particularly in Operation Uphold Democracy/Maintain Democracy, the deployment

of U.S. forces to Haiti, in which the Howard precedent would in fact be raised.99

Aeromedical Evacuation Becomes More User Friendly:

Operation Uphold Democracy

U.S. involvement in Haiti arose from a political crisis occasioned when the

first freely elected president in Haitian history, Jean-Bertrand Aristide, was

deposed by the military in September 1991. Following the turmoil, a UN sanction

was obtained authorizing the use of all necessary means to restore Aristide to

power.100 U.S. forces made a generally peaceful entry into Haiti on September 19,

1994, avoiding a forced entry that had already been set in motion and led by

SOCOM forces. Although no longer needed to force an entry, the JSOTF

remained at its base of operations at Guantanamo Bay, Cuba, longer than planned

to support other missions, and it retained operational control of the MASF and the

aeromedical evacuation personnel also deployed there.101

Upon Aristide’s return to Haiti on October 15, U.S. forces immediately began

withdrawing from a strength of 16,000 in late October to 9,000 by November 30.

By January, the United States had turned over command of the Haiti operation

officially to the UN, and residual U.S. troops were being provided aeromedical

evacuation services by TACC on a peacetime schedule using both C–9As and retrograde C–141 missions.102

Until that happened, patient evacuation was provided by a TAES that incorporated elements and policies differing rather sharply from the familiar aeromedical evacuation doctrine promulgated by the AMC and its predecessor, MAC.

The system also differed notably from the TAES that AMC’s 1st AMES had

deployed less than two years earlier during Operation Restore Hope in support

of U.S. forces in Somalia. However, the Somalia operation had evolved in ways

that compelled significant deviations from AMC policies regarding aeromedical

evacuation, which created the question, was Somalia a preview of the kinds of

contingencies that U.S. forces would be called upon to support in the future? If

so, how should the TAES be structured? Were the changes set in motion by

analyses of Desert Shield/Desert Storm relevant to the way the Air Force should

plan to conduct aeromedical evacuation in future contingencies? If it could be

said, as one of the authors of Colonel Brannon’s after-action report on Desert

Shield/Desert Storm did say several years later, that they had been wrong about

the type of future contingency the United States would have to support with

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aeromedical evacuation, then perhaps the operation in Haiti might be considerably closer to the correct model. Future contingencies requiring aeromedical

evacuation support will provide some answers to these questions, but a more

detailed description of the TAES that supported U.S. forces in Haiti can provide

some suggestive insights.

At first glance, the pattern of U.S. involvement in Haiti seems quite similar to

that pursued in Somalia. In both cases, once the decision to intervene had been

made, based at least in part on humanitarian considerations, large-scale U.S. forces

prepared to engage in combat deployed rapidly. Although the units deployed to

Somalia did not anticipate organized resistance and encountered none, they had

been authorized to use force under Chapter VII of the UN Charter to enforce a

Security Council resolution. In Haiti, anticipating resistance from the Haitian military from the start, the United States originally planned an assault to seize key

objectives and suppress opposition before it deployed the bulk of its forces. In

Somalia and in Haiti, plans called for the U.S. presence to be reduced after the initial operations and for the mission to be ultimately turned over to a UN-sponsored

multinational force that would have certain nation-building responsibilities.

Whatever apparent similarities existed between the two courses of U.S. involvement, more significant were the differences in the amount of resources devoted to

aeromedical evacuation and in the structure of the system itself. In support of

Operation Uphold Democracy, as the operation was initially codenamed, the further evolution of aeromedical evacuation in the USAF and the level of cooperation

with its major customer, the U.S. Army, for this support were significant.

In late April 1994, the 1st AMES, now assigned to the ACC, was requested

to participate in a joint exercise, Exercise Knightly Rogue. A FAST from the 44th

Medical Brigade and a joint medical augmentation unit with medical elements of

SOCOM were to participate. The SOCOM surgeon directing the exercise was

Colonel Volpe, who until six months before had served as the JSOTF surgeon for

the Ranger deployment to Mogadishu. Although not formally identified as such,

the exercise was a tacit rehearsal for deployment of a TAES to support a JSOTF

that would spearhead an invasion of Haiti. As reflected in the comments and recommendations in the 23d AMES103 commander’s unclassified after-action report

and verified by participants from the 1st AMES, the scenario and requirements

generated by the user, Colonel Volpe, and the SOCOM medical elements echoed

the use of the MASF as a JCCP during Operation Continue Hope, but they much

more closely resembled the system established at Howard AFB in Panama for

Operation Just Cause.104

Knightly Rogue reflected contingency planning that had begun quietly on a

very close-hold basis for a possible invasion of Haiti. The final CONOPS that the

planning group developed for the required aeromedical evacuation support of the

JSOTF that actually intervened in Haiti in September 1994 incorporated the

lessons and requirements of Exercise Knightly Rogue as well as well other elements interjected when the CONOPS was finalized.105

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New Contingencies
Essentially, two TAESs deployed to support Haiti operations, although the

system was conceived as a whole by the same small group of medical planners

who designed it over the course of several months preceding Knightly Rogue. The

planners were drawn from ACC, Twelfth Air Force, the 23d AMES, Joint Special

Operations Command, and the 18th Airborne Corp’s 44th Medical Brigade under

the leadership of ACC Chief of Medical Programs and Resources Col. James D.

Reay.106 One of the dual systems, based upon Knightly Rogue, supported

Combined Joint Task Force (CJTF) 180 whose core was a JSOTF assigned to

spearhead an invasion and to suppress resistance prior to the deployment of the

occupation/stabilization force, CJTF 190.

The JSOTF chain of evacuation for casualties led from the objective area in

Haiti, where emergency treatment was provided by special forces medics, to

transport via JSOTF helicopters to the USS America in the waters off Cuba.

Onboard the aircraft carrier, patients received surgical resuscitation from Air

Force surgical teams and were then medically evacuated to Guantanamo where

another Air Force surgical team stood ready to provide additional surgery if necessary. Patients were then transferred to the MASF which, in addition to its doctrinal role as a holding facility for patients awaiting evacuation (as in Mogadishu),

now had the additional function of serving as a JCCP.107

Evacuated patients were flown to one of three Navy hospitals at Jacksonville,

Florida, Charleston, South Carolina, or Portsmouth, Virginia, by C–130s previously deployed to Guantanamo and dedicated to the aeromedical evacuation support of the JSOTF. Four aeromedical evacuation crews also staged at Guantanamo

to provide en route medical care for stable patients. The ACC provided medical

augmentees to move stabilized patients. Flight surgeons had routinely augmented

aeromedical evacuation missions for the first time during Desert Shield/Desert

Storm. Now, for the first time in a contingency, three teams of physicians and specialists, designated as critical care air transport teams (CCATTs) and tailored to

the medical requirements of moving patients with various combat-generated

injuries, deployed to Guantanamo. Their presence eliminated one long-standing

irritant between the Air Force and the other services, particularly, the Army: the

AMC policy of requiring the respective service hospitals to provide attendants for

the evacuation of their patients who needed more than nursing care in the air.108

Another first for the TAES supporting the JSOTF was that all aeromedical evacuation personnel were chopped to the special forces for this part of the operation;

they were not controlled by the AECC. Practically speaking, this had the effect of

creating two separate TAESs as long as the JSOTF surgeon retained operational

control.109 In either case, a premium was placed upon timely evacuation because

the commander of the Atlantic Command, the supported CINC for the Haiti operations, had established an evacuation policy for combat casualties of one day

because of the austere medical capabilities in the AOR.110

The second TAES supported CJTF 190, which was composed of conventional combat and support forces built around elements of the 18th Airborne Corps

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and the 10th Mountain Division, the same organization that had provided the

quick reaction force in Mogadishu during UNOSOM II. The ACC also provided

medical augmentation for evacuating patients from CJTF 190, if needed, similar

to that provided for the JSOTF at Guantanamo. For this purpose, ACC deployed

ten flight surgeons, two general surgeons, one respiratory anesthesiologist, and

three CCATTs to Port-au-Prince, Haiti, where patient evacuation for the conventional forces originated.

In addition to its planned role as a occupation/stabilization force, CJTF 190

had also been envisioned as an alternative to the special operations units to deploy

and secure the island if a peaceful entry became possible. Planning for the two

CJTFs had been separate for security reasons, and the very late change of plan created a certain degree of overlap and confusion during the transition from CJTF

180 to CJTF 190 when the now peaceful invasion actually occurred. Shortly after

the troop deployment began, some 21,000 U.S. military personnel were in Haiti.

During the transition to CJTF 190, some of the pressure on the TAES was relieved

when Atlantic Command increased the theater evacuation policy for the routine

movement of patients to three days, and later to five days under CJTF 190 and the

succeeding multinational force.

The TAES had been designed to operate with the assumption of a forced entry.

Some aeromedical evacuation resources had to be redistributed to accommodate the

new reality, but the change was accomplished with no adverse effect. Changes in

evacuation policy had relieved some of the pressure on the TAES, but aeromedical

evacuation remained a critical element in the medical support of the large number of

forces entering Haiti because so few medical facilities were available. Aeromedical

evacuation of the conventional force patients continued essentially as planned.

Patients from CJTF 190 were stabilized by a FAST from the 5th MASH, and

then Army medevac helicopters flew them to the USNS Comfort, the veteran of the

Persian Gulf War, for definitive treatment and to await aeromedical evacuation.

Preplanned C–130 missions had been scheduled to depart MacDill AFB for Port-auPrince shortly after the U.S. entry, and general surgeons and flight surgeons at Pope

AFB had been placed on alert status to fly to Haiti with standard medical flight

crews to provide in-flight medical care should patients evacuated from Port-auPrince require it. Patient movement was accomplished using a combination of

opportune and retrograde airlift or by calling in one of the dedicated aeromedical

evacuation aircraft when a patient’s condition merited urgent evacuation. On

September 23, the first aeromedical evacuation mission flown from Haiti carried

eight litter patients, one classified as urgent, from Port-au-Prince to Jacksonville

Naval Station, Florida. Keesler AFB, Mississippi, was also used for urgent evacuees, but the primary destination for routine patients was Andrews AFB, Maryland.

Planning called for U.S. medical facilities at Port-au-Prince to be bolstered by a

combat support hospital soon after the U.S. deployments began.111

To ensure that the aeromedical evacuation system ran as smoothly as possible, AELTs were deployed widely to support the conventional forces of CJTF 190.

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New Contingencies
Teams were sent to Roosevelt Roads Naval Hospital, Puerto Rico; the amphibious assault vessel, USS Wasp; the USNS Comfort; and a central location at the

Port-au-Prince airport.112 The AELT deployed at Port-au-Prince coordinated the

required patient lift that carried patients to an appropriate CONUS MTF.

As the planned invasion transitioned into a permissive entry, the Port-auPrince AELT was replaced by a MASF. On September 28, the 28th Combat

Support Hospital from the 44th Medical Brigade deployed to Port-au-Prince to

provide a third-echelon MTF, and it began operations four days later. Both the

USNS Comfort and the FAST from the 5th MASH were redeployed to the

CONUS. The role of the 23d AMES was also terminated in early October when

it received another tasking to support a developing contingency in southwest Asia,

and it turned over the operation of the aeromedical evacuation system in the

Haitian AOR to an AFRES unit, the 610th AMES. The 610th managed the drawdown of the system as U.S. forces began to leave gradually in mid-October.

Between September 18 and December 12, 1994, a total of 118 litter and 207

ambulatory patients were aeromedically evacuated via the TAES.113

Unlike Operation Restore Hope, where few changes of any significance had

been structured into the supporting aeromedical evacuation system, the Haiti

TAES featured some novel elements. During the 23d AMES period of control, the

AECC that directed the TAES was located at Pope AFB together with an AME.

As an experimental measure prior to the initiation of Uphold Democracy, the

AECC was joined by personnel from the recently established GPMRC to establish a TPMRC that controlled the medical regulating of patients and, working with

the TACC at Scott AFB, patient movement.114

In another manifestation of AMC’s new role in medical regulating, deployable medical regulating teams equipped with leased IMARSAT terminals accompanied each AELT and the MASF/JCCP at Guantanamo Bay, Cuba. The teams

communicated patients to be evacuated to GPMRC representatives at the

AECC/TPMRC, who then regulated them to one of the three preplanned MTFs in

the CONUS. The teams manually entered the data into the DMRIS so that the

receiving facilities and the GPMRC had immediate access to patient information,

including data to provide in-transit visibility to the TRAC2ES.115 The experimental program for maintaining in-transit visibility of patients moving in the system

was paralleled by a program tracking patient movement items using another manual prototype of a capability planned for TRAC2

ES, once it was fully developed

and deployed. Related to this effort to ensure that patient movement items were

available where and when needed, the 23d deployed ventilators in large numbers

to Port-au-Prince to preclude any sending MTF (a FAST, the USNS Comfort, and

later, the 28th Combat Support Hospital) from leaving itself short of such equipment when it presented a patient for evacuation.116

AEOTs were deployed at bases where AECMs were staged, and in contrast

to initial phases of the intervention in Somalia, no friction between the AECC and

any of the operations teams in the Haitian AOR is noted. Although no significant

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combat casualties marked the operation, the TAES moved 118 litter and 207

ambulatory patients.

Communication among the various elements of the TAES was effective. In

addition to the standard Pacer Bounce HF system, the components employed

SATCOM and leased INMARSAT equipment, whose use Colonel Chester had

praised highly. Unique to Operation Uphold Democracy was the 23d AMES’s

development and publication of comprehensive flight crew guidelines outlining in

detail (and with diagrams) airfield landing locations, procedures, offload messages, and aeromedical evacuation kit inventories.117

In spite of an apparent record of success—Brig. Gen. James Peake, the JTF

surgeon, went on record after the operation saying “if you [aeromedical evacuation

people] had any problems, it wasn’t evident”—some problems with the TAES

operations were reported.118 Forty-four entries in the Joint Universal Lessons

Learned System described problems and issues related to aeromedical evacuation

that were raised during Operation Uphold Democracy/Maintain Democracy. Some

were familiar, such as the issue of a flight surgeon or a CCATT physician’s authority vis-à-vis that of an MCD, or the lack of adequate training for some of the ARC

personnel in contingency operations; yet some were new, such as determining the

best procedures for the TPMRC and deployable medical regulating teams to follow or, with reference to the aeromedical evacuation arrangements for the JSOTF

at Guantanamo, determining how to conduct tactical aeromedical evacuation when

significant parts of the system for evacuation were chopped to another agency.119

The management of the TAES seems to have been effective and flexible enough to

meet quite successfully the challenges posed by the shift in the character of the

U.S. entry into Haiti. The director of medical readiness at ACC, the command that

now had responsibility for tactical aeromedical evacuation, retrospectively stated

that the responsiveness of the aeromedical evacuation system was the most significant aspect of the way the TAES functioned during Operation Uphold

Democracy.120 The integrated personnel resources deployed from the 23d AMES

and the ARC in response to the 23d’s tasking were also adequate to the mission and

reflected imagination and creativity on the part of the planners who developed the

CONOPS for the aeromedical evacuation support of the Haiti operations.

The record of aeromedical evacuation support for these operations makes one

thing abundantly clear: the TAES for Operation Uphold Democracy was structured and operated in ways that differed markedly from the policies promulgated

by AMC and its predecessor MAC when they controlled the worldwide aeromedical evacuation system. AMC remained the Air Force proponent for aeromedical

evacuation after the decentralization of the worldwide system, but ACC now controlled both the C–130 tactical airlift and aeromedical evacuation units in the

active force and in the ARC. With the units had come ACC responsibility for the

tactical aeromedical evacuation mission and new ACC units, particularly the

active duty 23d AMES at Pope AFB with its unique and very rich experience in

tactical aeromedical evacuation planning and operations.

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New Contingencies
The 23d’s past close association with the 18th Airborne Corps and Army special operations units—in Grenada, Panama, the Persian Gulf, and Operation

Restore Hope—conditioned it toward close cooperation with the Army.

Additionally, as a very experienced AMC medical planner has pointed out, there

was an inherent management factor. Without AMC’s scope of responsibility for

aeromedical evacuation, which until mid-1994 encompassed three different systems—the strategic system, the domestic system, and the tactical system, all of

which utilized different aircraft for evacuation—ACC’s approach to the tactical

mission likely had a somewhat sharper focus and a greater energy.121

Certainly, ACC’s medical planners took a somewhat more responsive

approach to user requirements than AMC policies would have permitted. One

result was an ACC program to improve casualty care by more firmly establishing

an effective interface between the deployed Army health services support system,

including medevac helicopters and second- and third-echelon MTFs, and the Air

Force’s fixed-wing aeromedical evacuation system. This ACC program, stimulated in large part by discussions between Colonel Reay and the 18th Airborne Corps

command surgeon, General Peake, put both active duty and ARC personnel into

exercises with Army medical units at the Joint Readiness Training Center at Fort

Polk, Louisiana. ACC pushed this program quite intensively, having some 382

active duty and reserve aeromedical evacuation and medical personnel participate

in three joint readiness exercises in September 1995, October 1995, and January

1996.122

All these factors helped determine the thrust of ACC planning for the projected intervention in Haiti. Colonel Reay, who as ACC chief of Medical

Programs and Resources is generally credited with providing the guidance and

backing to the relatively junior planners who actually wrote the aeromedical evacuation CONOPS, was strongly oriented toward meeting the support requirements

of customers, particularly the Army units at Fort Bragg, with whom the 23d conducted many joint exercises and which tended to view AMC as unresponsive in

this regard.123 Another factor tending to differentiate perceptions of the tactical

aeromedical evacuation mission between AMC and ACC is the fact that when

ACC deploys combat or support forces, including aeromedical evacuation units,

they chop to a theater commander, whereas USTRANSCOM’s TACC continues

to exercise control over AMC’s strategic aeromedical evacuation missions in contingencies. Reay’s orientation toward satisfying the customer was not unique in

ACC. In February 1995 ACC Surgeon Brig. Gen. Thomas Gensler published a

generic ACC CONOPS for theater aeromedical evacuation whose core concept

was tailoring aeromedical evacuation forces to meet operational requirements.124

An interesting minor factor that contributed to the responsiveness with which

the ACC medical planners permeated the CONOPS for the Haiti TAES was one

that derived in part from recent history but had deeper roots in the long-standing

issue of whose responsibility it was to provide attendants for the air evacuation of

unstable patients. The issue became visible during the Persian Gulf War, but it was

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285

New Contingencies

muted in the aftermath by two facts: first, the Air Force flight surgeons had been

available to augment the standard aeromedical evacuation flight crews; second,

and more significantly, the number of patients who actually required aeromedical

evacuation was relatively small. The issue had become acute in Somalia because

the small staffs of the Army combat support hospitals providing medical support

to the residual U.S. force made losing any medical personnel risky. The security

situation had been uncertain for U.S. and UN personnel since the Somali attack

on Pakistani troops in early June, and U.S. installations at the Mogadishu IAP had

been periodically subjected to incoming fire of various sorts for weeks before the

Rangers attempted to seize Mohammed Aidid. In fact, at the time of the failed

Ranger raid of October 3, two members of the 46th Combat Support Hospital

medical staff were still in Germany awaiting transportation back to Mogadishu

after having accompanied patients from the support hospital on an aeromedical

evacuation to Ramstein.125

As Operation Continue Hope in Somalia was terminating, the Army’s unhappiness with the way the Air Force conducted aeromedical evacuation in contingencies became evident rather dramatically at a Fort Bragg conference that the

44th Medical Brigade sponsored in April 1994. Colonel Bloomquist from the

AMC surgeon’s staff briefed the attendees on the evacuation support the Air Force

provided in Somalia. In attendance from the Air Force was one of the medical

planners of the (still) 1st AMES from Pope AFB, Maj. James Lorraine, most of

whose squadron mates were participating in Exercise Knightly Rogue. What some

of the Army attendees objected to particularly, and apparently rather vociferously, was the Air Force policy that required MTFs to provide attendants for patients

that MCDs deemed would require possible medical intervention beyond the capabilities of the standard Air Force medical flight crew.126 Underlying the criticism

were the basic differences between the Army and Air Force on what clinical conditions should be acceptable for aeromedical evacuation, or what should disqualify certain patients pending a greater recovery. At issue was the ongoing argument

over the degree of clinical stability that constituted a stable versus a stabilized

patient, the latter requiring an attendant according to Air Force policy. Beyond the

clashing of clinical judgments (and possibly egos), the issue was made all the

more pointed for the Army medics because of the continuing drawdown of forward Army medical capabilities.

According to Major Lorraine, the criticisms leveled at the Air Force were so

agitating that, when he was tasked to help develop the CONOPS for the Haiti

operation, he determined he would seek to ensure that the Army would have no

reason to complain. This was a contributing factor to the development of a

CONOPS because its authors were already working actively to meet the requirements of their prime customer for aeromedical evacuation support in operations

into Haiti. In addition to the fulsome support previously described—the use of

dedicated aircraft for aeromedical evacuation, the deployment of flight surgeons

and CCATTs to augment standard medical flight crews, the forward deployment
of ventilators, and the tracking system for other patient movement items—there

was also a specific commitment of aircraft (C–21s) to provide the means to return

CCATTs to the points from which stabilized patients were to be evacuated to the

CONUS.127 Perhaps the most striking change from customary AMC policy and

practice regarding patient movement was the abrogation of the authority of an

MCD to decide when a patient was not clinically suitable for aeromedical evacuation. Instead, the OIC at each AELT was made the final authority on patient

movement, with the injunction that if a physician proffered a patient for evacuation, the patient was to be accepted without question and the standard medical

flight crew was to be augmented as necessary to provide care during the evacuation flight.128 In a later remark that reflected both his reaction to the Army criticism of the way in which the Air Force conducted aeromedical evacuation operations in Somalia and the configuration of the TAES that was deployed for

Operation Uphold Democracy, Major Lorraine said, “For Haiti we went in

‘heavy’ ... and [Lt. Col.] Phil Volpe got his own aeromedical evacuation system.”129

From a more analytical perspective, the way in which the TAES was structured and aeromedical evacuation was conducted during Operation Uphold

Democracy was clearly another and particularly significant step in the evolution

of the Air Force’s willingness and capability to carry stabilized patients, which

was something that MAC and subsequent AMC policy had sought to restrict.

Notably, the Haiti CONOPS and actual TAES took a major step toward answering the challenge posed by Colonel Carleton in 1991 that “we as a service need to

decide who our customer is, make this basic doctrinal decision, then organize,

train, and equip.” The customer during the Haiti operations, the U.S. Army, certainly got what it wanted. In addition to the comment of the JTF surgeon just quoted, SOCOM Commanding General Gen. Wayne A. Downing is on record as having commented that Operation Uphold Democracy was “the first time in his entire

service career he had ever seen all the medical pieces in all the right places at the

right time.”130 The Army clearly had reason to believe that the Air Force had finally accepted the Army’s position that whoever it asked the Air Force to evacuate

should be moved whenever the Army made the request.

Whether this in fact would become Air Force aeromedical evacuation doctrine remained to be seen. What the Army had witnessed was a difference in doctrine and policy, a result primarily from the transfer of AMC’s tactical airlift and

tactical aeromedical evacuation units to the tactically oriented ACC. In effect, this

mid-1994 transfer marked a reversion to the formal organizational dichotomy

between the strategic and tactical aeromedical evacuation systems that had existed throughout the Vietnam War until all airlift was consolidated under MAC in the

1970s.

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Chapter 12

EPILOGUE: EMERGING CRITICAL ISSUES

FOR REENGINEERING THE

AEROMEDICAL EVACUATION SYSTEM

Any fair evaluation of how well an aeromedical evacuation system performs

in a given contingency must consider what kind of operations the system was

designed to support, what resources were allocated to it, and what external factors

were considered when framing its structure. After the collapse of the Soviet Union

and the changes in the U.S. presidential administrations, successive DoD-directed bottom-up reviews (BURs) were conducted to determine the overall size and

capabilities that the defense establishment would need to meet major national

security challenges in a non–Cold War world. Worst-case exercises sought to

address two simultaneous major contingencies in different parts of the world.

Mobility requirement studies (MRSs) then sized the strategic airlift fleet against

airlift requirements to support these scenarios.1 Whatever data for deriving

aeromedical evacuation requirements the BUR provided to the related MRSs, it

seems that actual contingencies like Somalia and Haiti fell beyond the models.2

As Colonel Howell noted, the Persian Gulf War has not proved to be the model

for subsequent contingencies involving U.S. forces that Brannon and his staff had

predicted. Defining future aeromedical evacuation requirements and reengineering

the aeromedical evacuation system in light of the lessons of the Gulf War has

proved to be only partially relevant to subsequent later actual need. Somalia, Haiti,

and contingencies in the Balkans have proved more relevant in scale. The small

footprint of the Army’s forward deployed medical capability in contingencies since

Desert Storm has also tended to drive evacuation policy and impose a need to evacuate less stable patients than previously thought appropriate.

In the post–Gulf War era, when he became USTRANSCOM/AMC command

surgeon, General Roadman initiated strategic planning efforts focused on the

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Emerging Critical Issues
aeromedical evacuation system. Conceptually, these have now rightly been tied to

the BUR, its successive iterations, and related MRSs, and they have formed the

basis for several documents laying out what the future structure and capability of

the aeromedical evacuation system should be.3 Significant developments beyond

direct national security challenges facing the United States now assume everincreasing importance with respect to the future aeromedical evacuation system.

Diminishing Airlift Capability for Aeromedical Evacuation

As the 1990s progressed, perhaps the most fundamental problem affecting

the ability of AMC to fulfill its strategic aeromedical evacuation mission was the

declining number of aircraft in its inventory usable for strategic aeromedical

evacuation. Structural problems in the workhorse C–141 fleet had already affected deployment of the original contingent of U.S. troops to Somalia during

Operation Restore Hope, and proposals to use a service-life extension program

to extend the serviceability of the older C–141s had proved too costly.4 The

decline in the availability of aircraft capable of carrying up to 103 litter patients

on dedicated, scheduled, or retrograde missions created a dilemma that has yet to

be fully resolved.

A new strategic airlift aircraft, the C–17 Globemaster III, was intended to

replace the airlift capability lost when the C–141s left the inventory, but its procurement was slowed in the late 1990s because of problems in development. From

the point of view of performance, the C–17 is more capable than the C–141 in its

ability to carry outsized loads and to land at forward, unimproved airstrips.

Because the Globemasters were scheduled to replace the C–141s on a less than

one-for-one basis, fewer would be available for intertheater airlift of troops and

equipment or for aeromedical evacuation. In any major crisis requiring the intensive use of strategic airlift, taking C–17s out of the stream for even retrograde

aeromedical evacuation missions would present a problem.

In this regard, General Tenoso’s inability to keep the C–130s that he had

intended to reserve for aeromedical evacuation during Desert Storm from being

used for operational requirements is suggestive, particularly given the brief combat in which CENTCOM forces were engaged. Moreover, the total litter-carrying

capability in the strategic airlift fleet was going to be further reduced because

C–17 litter stanchions could accomodate only 36 litters, roughly one-third of the

C–141’s maximum capability.

The C–141 did not have the only airframe problem that affected the Air

Force’s capability to perform its aeromedical evacuation mission. The continuing

utility of dedicated C–9s for domestic and routine intratheater aeromedical evacuation missions also came into question in the middle of the decade. Their airframes were aging; some were nearly thirty years old. Although projected to be

airworthy until 2010, new and potentially costly requirements would be required

to keep the C–9s mission-ready. Should the Air Force wish to continue operating

288

A History of Aeromedical Evacuation in the U.S. Air Force
them for any purpose, new navigation equipment would be needed to meet the

reduced separation standards planned by the International Civil Aviation

Organization and the FAA. Furthermore, the C–9 logistics base was shrinking,

and new noise restrictions would require either the expensive option to re-engine

the aircraft or install hush kits, even though these had not yet been certified as

acceptable by the authorities. In 1999, the Secretary of State traveling on a C–9

converted for officials’ use had been refused landing at Brussels Zaventem Airport

because of its noise level.5

Potential solutions to both C–9 problems involved expenditures in an era of

tight Air Force budgets when the service would give higher priority to developing

new fighter aircraft, purchasing more C–17s, or re-engining the C–5 fleet to

increase its low reliability rate.6 A C–9 study completed in 1998 laid out potential

solutions among which the optimum appeared to be procuring the Boeing 757 as

a dedicated replacement, a difficult requirement to sell to the Air Force chief of

staff, given competing budgetary priorities.7

Whether to extend the viability of the C–9 fleet was complicated by the

reduced requirement for domestic aeromedical evacuation implicit in the organization of TRICARE, the new military health care system that went into effect in

mid-1998. TRICARE provides health care to active duty military personnel and

other eligible individuals regionally in geographically determined areas. Designed

to be medically self-sufficient, each region would offer a broad range of medical

specialties that would essentially eliminate or at least markedly reduce the need to

move patients among MTFs.

The rationale for the domestic aeromedical evacuation system itself had

already been questioned implicitly in 1995 in a joint evaluation by the DoD IG

and the Air Force Auditor General. The DoD IG review focused primarily on

whether the system was effectively meeting training requirements for its wartime

mission while providing cost-effective medical support in the process. The audit

concluded that DoD was performing unnecessary aeromedical evacuations and

that C–9As were being flown in excess of mission training requirements. Of 1,177

patients sampled between January and June 1993, the audit claimed that 983 could

have been treated locally and that only 79 patients were transported cost-effectively. It examined 425 USAF MTFs that used aeromedical evacuation to transport 424 outpatients to referral MTFs for routine medical care at a cost of $3,690

per patient. The agency’s analysis showed that comparable care could have been

purchased at local civilian sources for an average cost of $105 per patient. On this

basis, the agency calculated that the Air Force had spent approximately $29.8 million more than necessary in FY 1993 because it could have secured the same outpatient health care from local civilian sources. The agency report concluded, “the

aeromedical evacuation system was not an economical method for obtaining medical care for outpatients requiring treatment at alternate sites.”8 It also noted pointedly that C–9 aeromedical crews received only limited training because most

patients were ambulatory and did not require intensive medical care en route.9

289

Emerging Critical Issues
The report recommended that the C–9 flying-hour program be essentially

halved from 17,211 to 8,550 hours, which it believed would still meet training

requirements for the C–9A’s wartime mission. That mission had changed from

deploying the C–9s with their associated flight and medical crews overseas in support of NATO to remaining within the CONUS during contingencies.10 Although

rebuttals by the AMC command surgeon were eventually successful in adopting a

less stringent reduction—11,925 flying hours in FY 1997, 10,881 flying hours in

FY 1998, and 9,647 flying hours in FY 1999 and beyond—the C–9 program has

continued to come under attack.11

In 1998, the Office of the Secretary of Defense Program and Evaluation staff

attempted to eliminate the C–9A program entirely, but it was unsuccessful as a

result of the vigorous personal intervention of AMC Commander Gen. Walter

Kross who cited DoD reports stating that visible medical assets constituted the

single most important morale factor to combat troops, and that the C–9A constituted a major element of that visible presence. He also noted that the post–Gulf

War doctrine of accepting stabilized rather than stable patients for evacuation

required more aeromedical evacuation missions with more onboard specialized

medical equipment. With only limited intratheater airlift available to the warfighting CINCs, Kross argued that the additional loss of C–9As was especially worrisome. His concern with intratheater airlift had immediacy because the C–130 flying units and their associated tactical AMESs had reverted from ACC to AMC

control in mid-1997, and the reversion included the single active duty AMES dedicated to tactical aeromedical evacuation. The former 1st AMES based at Pope

AFB, North Carolina, that had gone into action as the 23d AMES in Haiti had now

become the 43d.12

Addressing the Strategic Airlift Shortfall

To help fill the gap in AMC’s strategic airlift capability caused by the loss of

C–141s, precedents from Operation Restore Hope offered at least a partial solution.

Some C–141B aircraft with low flight times on their airframes were distributed to

ANG and AFRES squadrons and were to be upgraded with new avionics to C models.13 General Fogleman’s directions to TACC that the cargo- and passenger-carrying capabilities of the KC–10s and KC–135s be utilized during the Somalia

deployments proved a successful expedient. The use of these aircraft provided not

only a substantial part of the necessary airlift capability, the additional aircraft

could also be used for retrograde aeromedical evacuation missions, albeit with

some limitations. Neither the KC–10 or KC–135 nor the C–5 was equipped with

litter stanchions; stanchions installed in the original C–135s used by MAC in the

early 1960s for aeromedical evacuation missions were removed in various depot

reworkings. More importantly, neither the KC–10 nor the KC–135 had oxygen systems configured to provide patient support, and in the case of the KC–135, the aircraft-generated power was incompatible with the airborne medical equipment.

290

A History of Aeromedical Evacuation in the U.S. Air Force
The ARC still had many KC–135 tanker units that were used for emergency

patient evacuations, and the activation of the aeromedical evacuation segment of

the CRAF could provide additional strategic evacuation capability, though the

CRAF option was not a viable solution for peacetime operations. Supported by

the AMC commander and the surgeon general, and pressed by the readinessfocused Carleton—who by 1998 was a lieutenant general and commander of the

Air Force flagship medical center, Wilford Hall, at San Antonio—AMC seriously studied the use of KC–135s to provide a peacetime supplement to AMC’s residual strategic aeromedical evacuation capability.14

Another possibility for resolving the peacetime shortfall of intertheater

aeromedical evacuation would be to acquire a new airframe like the Boeing 757-

300, modified for aeromedical evacuation. This was identified as the preferred

alternative to keeping and upgrading the C–9As, which the study concluded was

the least preferable option.15 The greater range and newer engine and navigation

technology incorporated in the 757 would enable it to perform not only intratheater but also intertheater airlift. The acquisition could be stultified by competing

priorities for aircraft acquisition and by a resurgent Air Force resistance to buying

single-purpose aircraft. Such an issue had surfaced initially in the early 1930s

when the Army surgeon general refused to buy additional dedicated air ambulances, and the Air Force was generally disinclined to buy a single-purpose transport aircraft. The C–131 and C–9 acquisitions really represent aberrations in Air

Force procurement policy.

In the much tighter budgetary world of the post–Cold War era, and in view of

a challenged peacetime domestic aeromedical evacuation mission, prospects for a

new jet aircraft dedicated to aeromedical evacuation were cloudy at best. Other

factors that arose in the late 1990s were the normalization of the role of critical

care in the air through the establishment and funding of the CCATTs; consideration of a possible new role for telemedicine in aeromedical evacuation and the

aggressive activity in a new mirror-force strategy to meld active duty and ARC

aeromedical evacuation communities into a seamless entity able to function efficiently in any contingency or full-scale wartime operation; and the provision of

sufficient airlift for strategic aeromedical evacuation, given the prospect of

C–141s leaving the inventory and the smaller litter capability of the C–17 coupled

with the issue of its greater operational value. Another factor profoundly impacting the resolution of these issues was the emergence of chemical and biological

threats to U.S. forces.

The Evolution of the USTRANSCOM Command and Control

and Execution System—TRAC2ES

TRAC2ES originated in the requirement to provide in-transit visibility for

patients moving within the strategic aeromedical evacuation system controlled by

MAC in the immediate post–Persian Gulf War period. While serving as USAFE

291

Emerging Critical Issues
command surgeon, General Roadman oversaw the successful development of a

limited in-transit visibility capability at the direction of the USAFE commander,

General Oaks. In this postwar period, TRAC2ES became a successful program for

AMC through General Roadman’s efforts and the able assistance of Navy

Commander Breeden, who originally had been critical of the Air Force’s

aeromedical evacuation effort during the Persian Gulf War.

As of October 2000, AMC had not yet been able to deploy an operational

TRAC2ES due to a variety of developmental problems which involved changes in

contractors and in the envisioned scope of the system. This latter change was initiated in the autumn of 1993 when an enthusiastic Government Auditing

Organization report recommended that the system be extended to patients evacuated by the TAES from the combat zone and the COMZ, rather than be developed

just for strategic intertheater aeromedical evacuation. Until achieving its anticipated full operational capability in 2001,16 the entire aeromedical evacuation system was subjected to a lengthy tiger-team effort assisted by the now-retired

Colonel Brannon to assess the requirements of the system to meet future challenges.17

A new mirror-force strategy has been put in place with apparently good

results to standardize capabilities between active duty aeromedical evacuation

units and those in the ARC. The lessons of the Haiti operation have now been

largely incorporated by AMC medical planners, who now include personnel from

the short-term ACC staff in control of tactical aeromedical evacuation. Among

them, the USAF surgeon general in 2000, Lt. Gen. P. K. Carleton, has by all indications carried his emphasis on aeromedical evacuation readiness to his staff.18

Perhaps, as always, budget priorities will determine the final shape of the

aeromedical evacuation system as it faces new challenges, now including the

transportation of patients suffering from the effects of biological, chemical, or

possibly even nuclear warfare. The aeromedical evacuation system planners have

prepared an excellent baseline from which to address these and other future challenges.

292

A History of Aeromedical Evacuation in the U.S. Air Force
Glossary

AAF Army Air Forces

ACTS Air Corps Tactical School

ADVON advanced party

AE/FS aeromedical evacuation flight surgeons

AEAM aeromedical airlift model

AECM aeromedical evacuation crew member

AEEB Aeromedical Evacuation Executive Board

AEF American Expeditionary Force

AELTs aeromedical evacuation liaison teams

AEOT aeromedical evacuation operations team

AERC Aeromedical Evacuation Readiness Committee

AESG Aeromedical Evacuation Steering Group

AESS aeromedical evacuation shipsets

AFMS Armed Forces Medical Service

AFSC Air Force Systems Command

AGE aerospace ground equipment

AID Agency for International Development

ALCC air lift coordination center

AMES Aeromedical Evacuation Squadron

AOR area of responsibility

ARC Air Reserve Component

ASD/HA Assistant Secretary of Defense for Health Affairs

ASF Army Service Forces

ASMRO Armed Services Medical Regulating Office

ATC Air Transport Command

ATG Air Transport Group

ATH air-transportable hospital

ATLS advanced trauma life support

C2 command and control

C3I command, control, communication, and intelligence

CBI China-Burma-India

CCATT critical care air transport team

293

Glossary
CENTCOM U.S. Central Command

CIM Corporate Information Management

CINCPAC Commander in Chief, Pacific Command 

CINCs commander in chief

CJCS Chairman, Joint Chiefs of Staff

CJTF combined joint task force

CMMS Congressionally Mandated Mobility Study

COCOM combatant command

COMALF Commander, Airlift Forces

COMZ communications zone

CONOPS concept of operations

CRAF Civil Reserve Air Fleet

CSF casualty staging flight

DEPMEDS deployable medical system

DIRMOBFOR director of mobility forces

DMRIS Defense Medical Regulating Information System

DNBI disease/non-battle injuries

DoD Department of Defense

DSN Defense Switched Network

FAA Federal Aviation Administration

FAST forward-area surgical team

FEAF Far East Air Forces

FEC Far East Command

FSE forward surgical element

FY fiscal year

GAO General Accounting Office

GHQ general headquarters

GNA Goldwater-Nichols Act

GPMRC global patient movement requirements center

HF high-frequency

ICAF Industrial College of the Armed Forces

IG Inspector General

INMARSAT International Maritime Satellite Network

ITV in-transit visibility

JALCO Joint Airlift Control

JCCP joint casualty collecting point

JCEWG joint casualty evacuation working group

JCS Joint Chiefs of Staff

JFACC Joint Force Air Component Commander

JLCOM Japan Logistics Command

JMRO Joint Medical Regulation Office

JSOTF joint special operations task force

JTF joint task force

294

Glossary
LOC line of communication

LSTs landing ship, tank

MAAG Military Advisory Assistance Group 

MAC Military Airlift Command

MACV U.S. Military Assistance Command, Vietnam 

MAES Medical Air Evacuation Squadrons

MAETS Military Air Evacuation Transport Squadron 

MAJCOM major command

MASF mobile aeromedical staging facility

MASH Mobile Army Surgical Hospital

MATS Military Air Transport Service

MCD Medical Crew Director

MEDSOM Medical Support Optical and Maintenance

MRS mobility requirements study

MTF medical treatment facility

NATO North Atlantic Treaty Organization

OASD/HA Office of the Assistant Secretary of Defense for Health

Affairs

OIC Officer-in-Charge

OPLAN Operation Plan

ORIs operational readiness inspections

PACAF Pacific Air Forces

PACOM Pacific Command

PDF Panama Defense Force

PSRC Presidential Selected Reserve Call-up

R&D research and development

ROK Republic of South Korea

RVN Republic of Vietnam

SAC Strategic Air Command

SACEUR Supreme Allied Commander, Europe

SAM School of Aviation Medicine

SATCOM UHF satellite

SHAPE Supreme Headquarters Allied Powers Europe

SOS Services of Supply

SSB/HF single-sideband high-frequency

T/O table of organization

T/O&E tables of organization and equipment 

TACC tanker-airlift control center

TAES tactical aeromedical evacuation system

TAMMIS Theater Army Military Medical Information System

TPFDD time-phased force deployment data

TPMRC theater patient movement requirements center

TQM total quality management

295

Glossary
TRAC2ES TRANSCOM Command and Control and Execution System

UMCC USEUCOM Medical Coordinating Committee

USAF U.S. Air Force

USAMA U.S. Army Materiel Agency

USAMMCE U.S. Army Medical Support Center, Europe

USAREUR U.S. Army Europe

USCINCEUR Commander, U.S. European Command

USEUCOM U.S. European Command

USNAVEUR U.S. Navy Europe

USSOUTHCOM U.S. Southern Command

USTRANSCOM U.S. Transportation Command

UTC unit type code

ZI zone of the interior

296

Glossary
BIBLIOGRAPHY

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Memorandum for Members of the Armed Forces Policy Council, subj:

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Memorandum from General Kenly to Col. Lyster, May 20, 1918. RG 18,

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Memorandum from Maj. Maxwell Kirby to Director of Military Aeronautics,

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Memorandum from the Director of Military Aeronautics to the Commanding

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Wolf, Richard I. The USAF: Basic Documents on Roles and Missions.

Washington, D.C.: Office of Air Force History, 1987.

Wolk, Herman S. Planning and Organizing the Postwar Air Force

1943–1947. Washington, D.C.: Office of Air Force History, 1984.

316

Bibliography
317

Notes

Notes
318

Notes
319

Chapter One

1. Eisenhower, Dwight D, Crusade in

Europe (London: William Heinemann

Limited, 1948), p. 347.

2. Mae Mills Link and Hubert A.

Coleman, Medical Support of the Army Air

Forces in World War II (Washington, D.C.:

Office of the Surgeon General, USAF, 1955),

p. 411.

3. Medical Support, p. 411. Aeromedical

evacuation in World War II will be discussed

in Chapter 3.

4. David M. Lam, “To Pop a Balloon:

Aeromedical Evacuation in the 1870 Siege of

Paris,” Aviation, Space, and Environmental

Medicine [ASEM] (Oct. 1988), pp. 988–9l.

Lam’s article prompted a letter from E.

Evrard, former director of the medical service of the Belgian air force, in which he

recounted a conversation between Armstrong

and the then senior French military doctor in

the early 1950s, Gen. Pierre Bergeret, for

which Evrard served as interpreter. As a

result of the discussion, Armstrong agreed to

delete the story from future editions of his

book, which by 1952 had gone through three

editions, because the French physician vigorously denied that such an evacuation could

have occurred. Bergeret provided supporting

historical data, whereas Armstrong could

provide none. ASEM (May 1989), p. 472.

For Gambetta’s flight, see Alistair Horne, The

Fall of Paris: The Siege and the Commune,

1870–71 (New York: St. Martin’s Press,

1965), pp. 84–85. The story of the balloon

evacuation from Paris still appeared in the

third edition of Armstrong’s book, which was

published before Armstrong’s encounter with

Bergeret; Principles and Practice of Aviation

Medicine (Baltimore: The Williams &

Wilkins Company, 1952), p. 421.

5. Sternberg’s selection over more senior

officers of the U.S. Army medical department caused the then Capt. Walter Reed to

remark that “the fossil age has passed.”

Quoted in Gillett, Mary C. The Army Medical

Department, 1865–1917 (Washington, D.C.:

United States Army Center of Military

History, 1995), p.10.

6. “The Collection and Evacuation of

Sick and Wounded from Front to Base,” The

Military Surgeon, vol. XL (June 1917), pp.:

611–12. Goodwin also noted that, obviously

based on British experience on the western

front, an average of 70 percent of an army

becomes incapacitated during the first year of

a war. “The Collection and Evacuation of

Sick and Wounded,” p.609.

7. Mary C. Gillett, The Army Medical

Department 1775–1818 (Washington, D.C.:

United States Army Center of Military

History, 1982), 74–75, 84. This seminal work

details medical aspects of the Revolutionary

War and the nature of the health problems

facing the U.S. Army, the organization and

functioning of the army medical department,

and its successes and failures in dealing with

the problems of disease and wounds during

the revolutionary and early national periods

in U.S. history, both in war and in peace.

Generally untreated by military historians,

these topics are essential for any serious student of U.S. military history and are covered

for later periods in Dr. Gillett’s subsequent

volumes, also published by the Center of

Military History, The Army Medical

Department 1818–1865 (1987) and The

Army Medical Department 1865–1917

(1995). The volume covering 1917–1941 is

currently in preparation; when completed, the

series will carry the story to the eve of World

War II.

8. Gillett, Army Medical Department

1775–1818, p. 20.

9. Quoted in Maj. James Robb Church,

“Notes on the Organization of the French

Sanitary Service,” The Military Surgeon 40

(July 1917): 536. The author of the article

entitled “Notes on the Infantry Attack,” from

which the quotation was taken, was a Major

Lachebre, who asserted that the comment

was still valid “today,” that is, during the

Great War. He asserted that the reason was

Preface
because, of all the echelons of the sanitary

service only regimental litter bearers had

shown no improvement since the beginning

of the war, thus creating the situation “that the

advanced portions of the battlefield are still

the lamentable domain of the saddest of

deaths, the slow death which comes from

lack of care,” (p. 536).

10. Archer Jones, The Art of War in the

Western World (New York: Oxford

University Press, 1987), pp. 272–73. See also

the incisive introductory essay by Stanley L.

Falk, in George C. Thorpe, Pure Logistics:

The Science of War Preparation

(Washington, D.C.: National Defense

University Press, 1986), Introduction,

xiv–xv. This is a reissue of one of the earliest

attempts to treat the problems of supplying an

army from a scientific perspective and was

originally published in 1917 by Thorpe, a

U.S. Marine Corps colonel. 

11. David G. Chandler, The Campaigns of

Napoleon (New York: The Macmillan

Company, 1966), p. 366. Larrey’s unintentionally prophetic term would be realized a

hundred years later. The effect of the tactical

situation on even the best systems was well

illustrated by the fact that thousands of

wounded French lay untended for more than

forty-eight hours on the battlefield of AspernEssling during the Danube campaign against

Austria, waiting for a bridge destroyed during the battle to be repaired, p. 708

12. The formation of the British Sanitary

Commission is described in an anonymous

historical essay, “The Geneva Red Cross

Movement. European and American

Influence on its Development,” in a special

issue of the Army Medical Bulletin 62 (May

1943): 7–9), which also contains the texts

with explanatory notes of all the Geneva and

Hague Conventions treating the issues of the

treatment of wounded, sick, and prisoners of

war by belligerent signatories.

13. Letterman’s system was extolled by

many authors who published articles in the

first decades of this century The Military

Surgeon, the journal of the Association of

Military Physicians. This was true of an

extraordinary series of four articles during the

mid 1920s by Lt. Col. T. L. Rhoads, who

pointed to the Letterman system as the “plans

on which that our present organization for

evacuation during combat is built.”

“Principles of Evacuation. II. Division

Evacuation,” The Military Surgeon 54 (Mar.

1924): 284. Rhoads makes clear that the presented “principles of evacuation” explicitly

reflected War Department planning for meeting the medical requirements of future army

defense planning and were based on what

Rhoads termed “exhaustive post-war analysis” of medical requirements for a theater of

operations drawn from U.S. experience in the

Great War. Quote from “Principles of

Evacuation. I. The Comprehensive Plan,”

The Military Surgeon. 54 (Feb. 1924): 133.

For a discussion of the origins of the U.S.

Sanitary Commission, see Anonymous, “The

Geneva Red Cross Movement,” pp. 9–29.

14. Gillett, The Army Medical

Department, 1818–1865, pp. 190–93,

293–98, et passim. The texts of Letterman’s

directives are published in Louis C. Duncan,

“Evolution of the Ambulance Corps and

Field Hospital,” The Military Surgeon 32

(Mar. 1913): 242–49.

15. James M. McPherson, Battle Cry of

Freedom: The Civil War Era (New York:

Ballantine Books, 1989), p. 485.

16. McPherson, Battle Cry, p. 209.

17. Maj. Raymond C. Turck, “Field

Maneuvers of Divisional Sanitary Troops,

Leon Springs, Texas, November, 1916,” The

Military Surgeon 40 (Jan. 1917): 156–70.

According to the author, these maneuvers

“were uniformly most interesting and

instructive for officers and men” and marked,

he believed, “a new era in the evolution of

modern medico-military work” that would

greatly improve “this branch.” The article is

illustrated by numerous photographs that picture the horse-drawn ambulances and wagons carrying the field hospital tentage and

320

Notes
equipment. The term “sanitary train” was

dropped in the post-World War I U.S. Army

reorganization in favor of “medical regiment.” The maneuvers were conceived and

directed by the then editor of The Military

Surgeon, Lt. Col. Edward L. Munson, who

noted that the ambulances and other components of the “train” needed to be better protected by being either marked more conspicuously with the red crosses called for by

international law or camouflaged to make

them as difficult as possible to be seen (pp.

157, 169–70).

18. For example, Colonel Rhoads lays

down the rules for animal evacuation in the

second part of his encyclopedic statement of

evacuation principles described in footnote

13. See Rhoads, Principles of Evacuation. II.

Division Evacuation, 314–17.

19. Goodwin, “The Collection and

Evacuation of Sick and Wounded,” 615.

20. Quoted in Tom Crouch, The Bishop’s

Boys: A Life of Wilbur and Orville Wright

(New York: W. W. Norton & Company,

1989), p, 252.

21. Crouch, The Bishop’s Boys, p. 252.

22. Robert F. Futrell, Development of

Aeromedical Evacuation in the United States

Air Force, 1909–1960 (Scott AFB, Ill.: 375th

Aeromedical Airlift Wing, 1977), p. 2. This is

a published version of an unedited draft historical study, Number 23, by Dr. Futrell that

he wrote in 1962 for the then Aerospace

Studies Institute at Maxwell AFB, Ala. Even

the strongly nationalistic Charles Julliot, a

member of the Aero-Club and an activist in

the cause of sanitary aviation, acknowledged

that—even if the concept had been “born” in

France—General de Mooy had been the first

person to conceptualize applying aviation to

military medicine. Charles Julliot,

“L’Aviation Sanitaire devant le VII Congres

juridique internationale de l’Aviation et la

XII Conference internationale de la CroixRouge,” Presse Medicale (Jan. 27, 1926):

124. “Horn,” writing in 1922, asserted that

the idea of using aircraft to transport wounded occurred simultaneously in 1910 to de

Mooy and to a French physician referred to

only as Dr. Teste. “Les Avions sanitaires dans

les guerres futures,” Paris Medicale: 365.

(Unless otherwise indicated, the author translated the articles cited from the original

French.)

23. Professor R. Blanchard,

“L’Association des Dames françaises,” Paris

Medicale (Feb. 13, 1915): 358; “Le transport

des blessés en aéroplane,” Paris Medicale

(July 1916): 53.

24. Blanchard, “Le transport des blessés

en aéroplane,” 53.

25. For consistency, the term air ambulance will be used interchangeably with its

European analogue, sanitary aircraft, to

denote a generic aircraft used to transport

patients. Aeromedical evacuation will be

used similarly with the European term sanitary aviation to denote the process of transportation.

26. Blanchard, “Le transport des blessés

en aéroplane,” 53.

27. The text of this and all other Geneva

and Hague Conventions governing treatment

of wounded and prisoners of war are printed

in Blanchard, “Le transport des blessés en

aéroplane.” Articles VI through XVII of the

1906 Convention cover mobile sanitary formations, pp. 100–103.

28. Emile Reymond, “Reconnaissance

des blessés sur un champ de bataille au

moyen de l’aéroplane,” Paris Medicale (May

2, 1913): 1033.

29. Maj. Médecin De Block, “Some

Notes on the First International Congress of

Medical Aviation,” Annales Belges de

Médecine Militaire, 82 (1929): 454. De

Block was a professor at the Belgian Ecole

Militaire, and in this article mentions that

Marvingt had convinced him that she had, in

fact, made such a proposal in 1912, by presenting him with documentary proof. In the

late 1920s, Marvignt served as vice president

of the international L’Amis de l’Aviation

Sanitaire (The Friends of Sanitary Aviation).

321

Notes
30. The article, “Avions sanitaire et conventions de la Croix-Rouge,” appeared in

Revue juridique internationale de la locomotion aerienne, III (Nov. 1912): 341. Reymond

refers to the 1912 Conference and Julliot’s

role in it in the question-and-answer period

following his 1913 presentation to the reserve

doctors. “Reconnaissance des blessés,” 1041.

One recent bibliography on aeromedical

evacuation lists twenty-six entries for Julliot

on sanitary aviation in journals published

between 1925 and 1937, seven of which deal

directly with the question of neutralization of

air ambulances in war. Karen Weitze,

Aeromedical Evacuation: Annotated

Bibliography (Brooks AFB, Tex.: USAF

Center for Environmental Excellence, Nov.

1994).

31. Reymond would be killed on another

reconnaissance mission early in the war.

32. Blanchard, “Le transport des blessés

en aéroplane,” 54. Quotation from Fritz

Bauer, “Experiments with Aeroplanes used

by the Medical Services in War and

Peacetime,” Journal of the Royal Army

Medical Corps, LII (Feb. 1920): 82.

33. Blanchard, “Le Transport des blessés

en aéroplane,” 54–55. Blanchard cites published accounts by two French newspaper

correspondents; one apparently accompanied

the French expeditionary force, and the other

interviewed one of the survivors, Lt.

Stefanik, in a Rome hospital in Dec. 1915.

34. Bauer, “Experiments with

Aeroplanes,” p. 82. The quotation is from

Futrell, The Development of Aeromedical

Evacuation, p. 2. Chassaing’s cultivation of

the parliamentary committees is described in

Paris Medicale XXVI (1917): 435. Horn,

“Les Avions sanitaire dans les guerres

futures,” 365–66. In an article by Col. Robert

Picque published in translation in the May

1924 issue of The Military Surgeon,

Chassaing supposedly was allocated the sixty

Breguet two-seaters in 1916, but this is clearly an error of translation or editing. Picque

was an honorary member of the U.S.

Association of Military Surgeons, and, until

he died in an aircraft accident in 1925, was

perhaps the most vigorous French uniformed

proponent of air ambulances. Prof. Lejar,

“Robert Picque,” and Charles Julliot, “Le

professeur Picque et l’Aviation sanitaire,”

both in Presse Medicale (June 11, 1927):

748, 748–49, respectively. Picque was

memorialized in The Military Surgeon 63,

(Oct. 1929): 612–14. Also see Jean-Bernard

Paillou, “Robert Picque: Pionnier de

L’Aviation Sanitare” (Bordeaux, France:

Universite de Bordeaux, 1970). This is

Paillou’s published thesis for his doctorate in

medicine. I am indebted to Michel-Ivan Louit

for bringing this work to my attention.

35. The article is brief but cites the

Villacoublay experiments as “the first practical test of a true twentieth century means of

transporting the seriously wounded to base

hospitals via the air route.” The aircraft is

shown with red cross markings in flight and

with the litter compartment open ( Nov. 24,

1917, p. 385).

36. Bauer, “Experiments with

Aeroplanes,” 82–83. C. Legrand,

“L’Aviation et le service de santé en campagne,” Archive de Médecine et de

Pharmacie Militaires 61 (1913): 538–40.

Legrand enthusiastically hailed Dr.

Reymond’s talk to a meeting of reserve doctors and agreed with Reymond’s advocacy of

air ambulances for the army. In his remarks,

Reymond had, in addition to describing his

participation in the 1912 army maneuvers,

also pointed to the value of being able to fly

doctors about within the French colonies

where surface transportation was very slow,

thus saving time, money, and [interestingly]

“escorts.”

37. Julliot, “L’Aviation Sanitaire,” 124.

38. Crouch, The Bishop’s Boys, pp.

368–69, 375–78, 398–99.

39. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 2. Futrell had

access to a letter, written long after the fact,

from Gosman to Ernest Larue Jones, on Aug.

322

Notes
19, 1947, recounting what he and Rhoades

had done and how it had been received.

40. Futrell, Development of Aeromedical

Evacuation in the USAF, p, 2.

41. Lt. Col. David N. W. Grant, “Airplane

Ambulance Evacuation,” The Military

Surgeon 88 (Mar. 1941): 239.

42. Col. A. W. Williams, “The Flying

Ambulance,” The Military Surgeon 92 (Apr.

1943): 445–46.

43. Williams, “The Flying Ambulance,”

446.

44. Ibid.

45. Irving B. Holley, Ideas and Weapons.

Exploitation of the Aerial Weapon by the

United States during World War I: A Study in

the Relationship of Technological Advance,

Military Doctrine, and the Development of

Weapons (Washington, D.C.: Office of Air

Force History, 1983; reprint of the original

edition published by Yale University Press in

1953), pp. 37, 149. Maurer Maurer, Aviation

in the U.S. Army, 1919–1939 (Washington,

D.C.: Office of Air Force History, 1987), p. 5.

Maurer describes the organizational changes

in the control of U.S. Army aviation on pp.

xxi–xxii. The armistice strength figures used

are from Maurer; Holley uses figures of

“more than 150,000 and 15,000 aircraft,” but

his book compares production programs in

terms of numbers of squadrons exclusively.

Maurer, therefore, appears somewhat more

credible.

46. Link and Coleman, Medical Support

of the Army Air Forces in World War II, p. 11.

The figure of 90 percent for British casualties

caused by physical defects in the first year of

war was used in a lecture to a graduating

class of flight surgeons at the School of

Aviation Medicine sometime late in 1918

before the armistice. The same figure of 90

percent was used later by Lt. Col. C. L.

Beaven in 1938 in a chronology of aviation

medical events. Which figure (60 or 90 percent) is correct is in one sense immaterial

because, whatever the number, it was high

enough for the British army to take remedial

action and the U.S. Army to embark on

research to determine the most valid standards possible. Anonymous, Lecture to

Graduating Flight Surgeons, Mitchel Field.

n.d., Entry 94, 321.9, General, box 2, Record

Group (RG) 18, National Archives (NARA) .

Beaven, “Chronological Notes on Aviation

Medicine,” Army Medical Bulletin (Jan.

1940), 52; abridged reprint of an article in

Flight Surgeon Topics II (Oct. 1938).

47. Armstrong, Principles Practice of

Aviation Medicine, p. 29.

48. Link and Coleman, Medical Support

of the Army Air Forces in World War II, p.

11–12.

49. Ibid., pp. 15–20.

50. Maurer, Aviation in the U.S. Army,

1919–1939, pp. xxi–xxii.

51. “Airplane Crashes, 1918 and 1919, in

the United States Army Air Service,” Air

Service Information Circular (Aviation) IV

(May 1, 1922): 1. The remaining 1,161 crashes were not included either because they were

minor or because they occurred at sites too

remote for flight surgeons to make an investigation. Similar gaps in the data and a lack of

knowledge of how the criteria, for example,

“injured,” were defined, suggest that the specific numbers should be accepted with some

caution. Looking at the statistics for calendar

years 1917 through 1921, and 1924 through

1926, inclusive, the numerical relationships

among the categories are remarkably consistent, that is, roughly the same percentages of

crashes occurred during landing, the same

percentage of crashes occurred more than fifteen miles from the field, and the same percentage of the total crashes resulted in fatalities in all these years. The May 1922 Circular

also contains crash data for 1920 and 1921.

Crash data for calendar years 1924 through

1926 is in the statistical reports on airplane

crashes in the Air Service that were prepared

semiannually for the chief of the Air Service

by the Medical Section covering the preceding six-month periods of each calendar year;

box 1, Entry 94, Decimal 319.1, RG 18,

323

Notes
NARA.

52. H. Graeme Anderson, The Medical

and Surgical Aspects of Aviation (London:

Oxford University Press, 1919). Anderson’s

introduction is dated Nov. 5, 1918.

53. Ltr, from Surgeon, Rockwell Field, to

Chief Surgeon, Aviation Section, Signal

Corps, Feb. 12, 1918, printed in Grant,

“Airplane Ambulance Evacuation.” The

Military Surgeon 88 (March, 1941): 239.

Ream was the first flight surgeon to be placed

on flying status and also the first to be killed

in an aircraft accident, on Aug. 24, 1918.

Note to Grant article. While Ream’s decision

to fly medical personnel to crash sites might

also suggest that information flowing back

from Europe was the source of the idea, it is

more probable that the availability of twoplace aircraft and concern for the health of

the downed fliers determined adoption of this

procedure. However, British personnel learning to fly at at least one field in Texas might

also have served as an information conduit

regarding developments on the western front.

54. Quoted in Anonymous, “Airplane

Ambulances,” The Army Medical Bulletin 2

(Feb. 28, 1922): 42, Weitze Collection.

55. Lt. Col. Frederick R. Guilford and

Captain Burton J. Soboroff, “Air Evacuation.

An Historical Review,” The Journal of

Aviation Medicine 18 (Dec. 1947): 602–603.

Guilford had been chief of the Air Evacuation

Department, School of Aviation Medicine.

However, the article contains no footnotes,

and some evidence conflicts with the claim

made in it that there were two successive air

ambulances developed at Ellington Field

based on modifications to the Curtiss JN–4s

used for training. Also see Futrell,

Development of Aeromedical Evacuation in

the USAF, p. 4. Precisely when the first evacuation flight was made is not clear from the

published information on the subject. The

commander of Gerstner Field wrote to the

director of military aeronautics, Maj. Gen.

William Kenly, on July 15, 1918, that the air

ambulance at Gerstner had been used continuously since “about May 1st.” Guilford and

Driver also disagree with Futrell on Driver’s

first name, “Nelson” in the article just cited,

and “Wilson” according to Futrell.

56. Capt. Norvelle Wallace Sharpe, “The

Ambulance Airship. A Factor Making for

Improved Articulation between the Medical

Department and the Flying Officer,” Annals

of Surgery 68 (Nov. 1918): 526–27.

57. The engineering sketch is on a foldout

following p. 528.

58. Reference to Royal Flying Corps

trainees is in Report, Post Hospital, Taliaferro

Field, Hicks, Tex., to Chief Surgeon, Aviation

Section, Apr. 2, 1918, in “Extracts from

Reports of Flying Fields Relative to the

Supply of Heavy Type of Ambulance,”

attached to Memo for the Surgeon General

from the Chief Surgeon of the Aviation

Section, Signal Corps (Lyster), subj:

Improved Type of Ambulance at Flying

Fields, May 18, 1918, Office of the Chief of

the Air Corps, Central Decimal Files,

1917–1938, 452.1, box 1712, RG 18, NARA.

59. A pertinent example is the personal

letter one young flight surgeon wrote to Col.

Albert Truby, chief of the U.S. Army medical

department in the early 1920s. Aware that a

friend had requested his transfer by name to a

nonflight surgeon’s position in the Air

Service at Chanute Field, Ill., the young captain pleaded to be left as a flight surgeon at El

Paso, Tex. He was flattered by the name

request, but he did not want to go because he

was “much in love with my flight surgeon’s

work” and, even though he would still be in

the Air Service, “it would not be in the active

end of the game.” He also told Truby that

being in the Air Service and doing flight surgeon’s work was the one reason that he had

stayed in the service. Handwritten Ltr, Capt.

David A. Myers, to Col. A. E. Truby, Dec. 29,

1920. Copy in possession of the author. For

his work six years later, Myers was to be

credited in 1938 by the future chief of the

U.S. Army medical department, Lt. Col. C. L.

Beaven, with establishing the principles upon

324

Notes
which “the art of blind flying” (flying solely

by instruments) was founded by Lt. Col.

William C. Ocker. Beaven, “Chronological

Notes on Aviation Medicine,” The Army

Medical Bulletin (Jan. 1940): 57. Ocker had

earlier been responsible for the development

of the first air ambulance at Gerstner Field.

One retired U.S. Army doctor with a long

professional experience in the history of

medicine who agreed with this characterization called this the difference between preventive and curative medicine. Interview, Dr.

Robert T. Joy, Colonel, U.S. Army (Ret.),

Mar. 19, 1996. Dr. Joy directed the Medical

History Program of the Uniformed Services

University of the Health Sciences at the time

of this interview.

60. The governing regulation is quoted in

a lengthy article in W. L. Sheep, “Air Medical

Service. The Flight Surgeon, a New

Specialist in Medicine,” Air Service

Information Circular (Aviation) (ASIC)

III:237 (July 15, 1921): 4.

61. Of forty flight surgeons on duty at Air

Service stations in 1921, twenty-nine were on

flying status, seven were qualified pilots, and

five were taking pilot training. “The Flight

Surgeon,” pp. 3–4.

62. The National Library of Medicine

(NLM) collection is based on the Surgeon

General’s Library, which by the turn of the

century had more medical publications than

the two next largest U.S. medical libraries

combined. Among its serial holdings was

Scientific American, which began publication in 1845. Gillett, The Army Medical

Department, 1865–1917, p. 27. Conference

with Reference Section, NLM, Mar. 18,

1996, by the author.

63. Ltr to Maj. Gen. William L. Kenly,

June 26, 1918, RG 18, Entry 166, OCAC,

General Correspondence, 1917–1938, 451.8,

Ambulances, box 951, NARA. The copy of

Lazaro’s letter in the files has the initial “A”

before his last name; however, the response

from Kenly was addressed to “Ladislas”

which suggests the stenographer who copied

the original letter made an error.

64. Maurer, Aviation in the U.S. Army,

1919–1939, pp. 39–40.

65. Memo, for Colonel Davis from 1st Lt.

Grover O’Neill, June 28, 1918; message:

Kenly to CO, Gerstner Field, July 3, 1918,

Entry 168, OCAC, Correspondence,

1917–1944, Gerstner Field, 452.1, box 1712,

RG 18, NARA.

66. Telegram, Maj. Isaac H. Jones to

Chief Surgeon, Aviation [Lyster], May 3,

1918, in Extracts from Reports of Flying

Fields Relative to Supply of Heavy Type of

Ambulance. In the organizational arrangements of the time, Jones, the doctor concerned with the health and maintenance of

flying personnel, worked for the post surgeon.

67. Memo from General Kenly to Col.

Lyster, May 20, 1918, Entry 166, OCAC,

General Correspondence, 1917–1938, 451.8,

Ambulances, box 951, RG 18, NARA.

68. Memo from Maj. Maxwell Kirby to

Director of Military Aeronautics, July 15,

1918, subj: Hospital Ship. Entry 166, OCAC,

General Correspondence, 1917– 1938, 451.8,

Ambulances, box 951, RG 18, NARA.

Presumably, the “tracing” was of the blueprints used to modify the JN–4.

69. Memo from the Director of Military

Aeronautics to the Commanding Officers,

All Flying Fields, July 27, 1918, subj:

Ambulance Planes; and Ltr, Lt. Col. F. R.

Kenney to the Honorable Ladislas Lazaro,

July 24, 1918. Both documents are in Entry

168, OCAC, Correspondence, 1917–1944,

Elling ton Field, 452.1, box 1615, RG 18,

NARA. 

70. Ltr, Maj. W. H. Frank to the Director

of Aeronautics, Training Section, Attention:

Major Millard F. Harmon, Aug. 26, 1918,

subj: Airplane - Ellington Field, Entry 168,

OCAC, Correspondence, 1917–1944,

Ellington Field, 452.1, box 1615, RG 18,

NARA. In a letter written long after the

event, Maj. Gen. Harry Johnson, USAF

(Ret.), who was a student pilot in Texas at the

325

Notes
time, related that the first air ambulance he

ever saw was in the summer of 1918 when a

Lieutenant Carlson was evacuated from

Brenham, Tex., to the Ellington Hospital with

a broken leg suffered in a crash. According to

Johnson, who had also suffered a crash at

Brenham the same day, but without injury,

Carlson was the first patient evacuated in the

converted JN–4. Ltr, General Johnson to the

Public Relations Office, School of Aviation

Medicine, Brooks AFB, Tex., Jan. 15, 1968,

Archives, Edward H. White Memorial

Museum, Brooks AFB.

71. David M. Lam, “Kelly’s Hospital

Ship,” Aviation, Space, and Environmental

Medicine 63 (Dec. 1992): 1115. Maj. S. M.

Strong, “Aero Ambulance,” The Military

Surgeon 44 (Apr. 1919): 361. Strong’s short

article is illustrated with four pictures, three

of which show the patient in a rather unusual

litter.

72. Memo, for Chief of the Engineering

Division, McCook Field, from Office of the

Director of the Air Service, subj: Airplane

Ambulances, Dec. 6, 1919, Entry 166,

OCAC, General Correspondence,

1917–1938, 451.8, Ambulance, box 951, RG

18, NARA. The specifications are also quoted in Colonel Truby and Maj. John Dibble,

“Operation of the Medical Division of the Air

Service since the Signing of the Armistice,”

The Military Surgeon 47 (July 1920)

73. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 5.

74. For a brief biographical sketch of

Truby, see The Army Medical Bulletin 33

(1935): 15–16.

75. Grant quotes Truby’s statement of the

future purposes of air ambulances in full in

“Airplane Ambulance Evacuation,” p. 241.

Maj Louis H. Bauer, “Aviation Medicine. An

Outline of the Progress in Research and

Teaching of this subj in the United States during the Calendar Year 1921,” ASIC IV:359

(Aug. 1, 1922): 19–20.

76. Quotations are from “Airplane

Ambulance Evacuation,” pp. 240–41. See

also Futrell, Development of Aeromedical

Evacuation in the USAF, p. 5. Grant, who

several months after publication of his article

would become the first air surgeon of the

Army Air Forces, characterized the results of

this episode as having “probably set back the

development of aerial evacuation at least ten

years.”

77. Maurer, Aviation in the U.S. Army, pp.

44–46.

78. The situation is depicted graphically

in some fifteen endorsements to a communication regarding a report of a flying accident

sent to Maj. Gen. Mason Patrick, Chief of the

Air Corps [CAC], by the army adjutant general’s office [AGO] in Sept. 1925. In his

endorsement back to the AGO, Patrick

requested immediate consideration to providing comfortable and speedy ambulances for

emergency use at flying fields and upgrading

passenger cars with more-modern equipment. In terms similar to those used by his

predecessor, General Kenly, seven years

before, Patrick argued that surveys he conducted at thirty-eight sites, eleven of them

under his jurisdiction, showed that motor

transportation was inadequate. Cars were

quite old, of 1918 or earlier vintage, and

unreliable because of heavy previous usage.

Ambulances had the speed, comfort, and riding qualities “of a truck” and were clearly

unsuited for the task of timely retrieval of

severely injured crash victims who were

often retrieved at some distance from the

post, were usually in profound shock, and

were, in general, in need of prompt and careful treatment to survive. 2nd Endorsement,

CAC to the AGO, Nov. 30, 1926, Entry 166,

OCAC, General Correspondence,

1917–1938, 451.8, Ambulance, box 951, RG

18, NARA.

79. Futrell, Development of Aeromedical

Evacuation in the USAF, pp. 6–7.

80. Ibid., p. 6. Their report was published

in the ASIC. Verville had earlier supervised

the modification of the DH–4s into air ambulances.

326

Notes
81. Ibid. See Maurer, Aviation in the U.S.

Army, pp. 177–82, for a description of the

T–2 flight.

82. Dr. Robert Picque, “L’air medical service et l’aviation sanitaire aux Etats-Unis,”

Archives Belges de Médecine Militaire 78

(Feb. 1925): 60–73.

83. Meetings were held biennially, with

the first official (and funded) U.S. delegation

sent to the Sixth Congress at The Hague in

1931. Maj. Edgar Erskine Hume, “The

International Congress of Military Medicine

and Pharmacy,” The Army Medical Bulletin

32 (July 1935): 34–38.

84. William Seaman Bainbridge, “Report

on ‘Congrès international de la médecine et

de pharmacie militaries,’ held in Brussels,

Belgium, July 1921, and Meeting of the

‘Comité Permanent,’ held in Brussels,

Belgium, February 1922,” U.S. Naval

Medical Bulletin XVII (Dec. 1922), pp.

962–63. Uzac had accompanied Colonel

Picque to the San Antonio meeting of the

Association of Military Surgeons and had

also been active in the prewar activities of Dr.

Duchaussoy and Charles Julliot concerning

applying aircraft to the relief of the wounded.

85. One of the four major topics discussed

was “General Principles of Evacuation of the

Wounded in the Fighting Armies.

Organization of such Evacuations taking into

Account the Exigencies of Therapeutic

Needs. Adaptation of Medical and Surgical

Therapy to the Various Conditions Resulting

from the Necessity of Evacuation of the

Wounded.” William Seaman Bainbridge,

“Report on Second ‘Congrès international de

médecine et de pharmacie militaires’ and

Meetings of the ‘Comité Permanent,’ held in

Rome, Italy, May–June 1923,” The Military

Surgeon LV (Dec. 1924): 764, et passim.

86. Maj. Dr. De Block, “Some Notes on

the First International Congress of Medical

Aviation,” p. 458.“”

87. De Block, “Some Notes,” pp. 458–60.

Emphasis added.

88. De Block, “Some Notes,” p. 462.

89. De Block, “Some Notes,” p. 462.

90. For example, Paul des Gouttes, “La

question de l’immunisation des avions sanitaires et le projet de Convention internationale sur la guerre aérienne,” Revue

Internationale de la Croix-Rouge 12 (July

1930): 481–87. Des Gouttes and Charles

Jolliot were frequent contributors on issues

arising under the Geneva Convention.

91. Monthly Bulletin of the League of Red

Cross Societies XVI (Jan. 1935): 13, 185.

92. Dr. Zeno Mataloni, “Adaptation du

brancard de campagne standardisé aux

avions sanitaires,” Revue Internationale de la

Croix-Rouge 12 (Nov. 1930): 945–46.

General Ireland had suggested that a smaller,

simpler cradle-splint device, of which he sent

sketches and photographs, would be perfectly adequate for carrying litter patients on air

ambulances.

93. Two French medical officers who

accompanied the campaign described the

problems encountered by the sanitary service

in a lengthy article published in 1913. Drs.

Wisseman and Renaud, “Le Service de santé

in campagne au Maroc occidental Octobre

1911–Avril 1912,” Archives de Médecine et

de Pharmacie Militaires LXI (Jan. 1913),

182–228.

94. Prof. Theodore Tuffier, “Aviation and

Wounded in the Desert of Sahara,” translated

from the French by James Robb Church, The

Military Surgeon XL1V (May 1919):

437–41.

95. General Dr. Fritz Bauer,

“Experiments with Aeroplanes used by the

Medical Services in War and Peacetime,”

translated by Major A. D. Sterling, Journal of

the Royal Army Medical Corp. LII (Feb.

1929): 83. Dr. Epaulard, “L’aviation sanitaire

au Congrès international de Médecine et de

Pharmacie militaires,” La Presse Medicale

(May 2, 1925): 580. Numerous articles in La

Presse Medicale and Paris Medical during

the 1920s touch upon the results obtained by

sanitary aviation in the colonial areas, particularly Morocco and Syria. For example, the

327

Notes
latter journal reported that M. Tilmant had

presented sketches and photographs of socalled aérochirs to a meeting of the Medical

Society of Paris on June 13, 1924 and

described the results of their use in Morocco

and Syria. Aérochirs were specially equipped

air ambulance aircraft that carried surgical

and other medical equipment on board and

were used to fly surgeons to places where

their skills were needed and evacuate victims, as needed. Paris Medical, LIV (1924):

138. Their equipage is described in “Les

Essais d’un Avion radio-chirurgical,” Paris

Medical, XXXII (1919), p.117.

96. Colonel J. A. Schickele, “L’aviation

sanitaire sur les T.O.E. et dans l’Afrique du

Nord en 1933,”] Archives de Médecine et de

Pharmacie Militaires CL (Sept. 1934): 258.

97. P. Desfosses, “L’Aviation sanitaire au

XIIe Salon de l’Aeronautique,” La Presse

Medicale (Jan. 31, 1931): 157–58.

98. Donegan, “The Relation of and Utility

of Aeroplanes in Connexion [sic] with

Medical Services in the Field,” The British

Medical Journal (Aug. 9, 1913): 304.

Donegan is probably the “Colonel Donovan”

referred to by Air-Commodore David Munro

in his Presidential Address to the War Section

of the Royal Society of Medicine in 1924,

who, Monro said, approached the War Office

before the war with a “scheme” for carrying

sick and wounded by airplane. Proceedings

of the Royal Society of Medicine 17:III

(1924): 7.

99. M. D. Scholl, and C. L. Geshekter,

“The Zed Expedition: the World’s First Air

Ambulance?” Journal of the Royal Society of

Medicine 82 (Nov. 1989): 679–80.

100. Capt. J.C. Burns, “A Note on the

Evacuation of Service Casualties by Air”

Journal of the Royal Army Medical Corps 46

(Mar. 1926): 202–205.

101. Sir John Slessor, The Central Blue:

The Autobiography of Sir John Slessor,

Marshal of the RAF (New York: Frederick A.

Praeger, 1957), 51–73.

102. Wng Cdr H. A. Treadgold, “Aerial

Transport of Service Casualties,” Journal of

the Royal Army Medical Corps XLV (Nov.

1925): 343. The article, covering pages

321–43, has photographs of both the Vickers

Vernon and Avro “Andover” ambulances.

The British did not build an aircraft specifically dedicated to aeromedical evacuation

until 1936. Bulletin of the League of Red

Cross Societies XVII (July 1936): 107.

103. For example, Capt. Robert K.

Simpson, “The Airplane Ambulance—Its use

in war,” The Military Surgeon LVII (Jan.

1929), 35–48.

Chapter Two

1. See Chapter 1.

2. Futrell, The Development of Aero -

medical Evacuation in the USAF, p. 7.

3. Ibid., p. 6.

4. Ibid., p, 7. C. L. Beaven, “Airplane

Ambulance Evacuation of Tornado Victims

at Rocksprings, Texas,” in “Medical and

Military Notes,” The Military Surgeon 61

(July 1927): 99–101. The evacuation from

Rock Springs, some 125 miles from San

Antonio, took place on Apr. 13–14, and was

directed by Beaven, then a flight surgeon at

Kelly Field.

5. Lt. Col. T. E. Darby, “Airplane Ambu -

lance Evacuation,” The Military Surgeon 70

(Aug. 1932): 163. Futrell, The Development

of Aeromedical Evacuation in the USAF, p. 7.

6. Hathaway had cited both future “military necessity” as well as “present needs” in

making his pleas in 1929. Futrell, The

Development of Aeromedical Evacuation in

the USAF, p. 7. However, given the effective

ambulance service being provided by C–1s,

which were converted transports, Hatha -

way’s was probably motivated by his recognition that, unlike the Cox-Klemins, transport

type aircraft were generally less suitable for

crash rescue-type work.

7. Lt. Col. Frederick R. Guilford and

Capt. Burton J. Soboroff, “Air Evacuation.

An Historical Review,” Aviation Medicine

328

Notes
(Dec. 1947): 605. Futrell, The Development

of Aeromedical Evacuation in the USAF, p. 7.

The Ford was evidently immediately reconverted because there is no further mention of

it in the Surgeon General’s reports or in the

articles written by those medical department

proponents of air ambulances.

8. Memo, Brig. Gen. Oscar Westover,

Act ing Chief of the Air Corps, for the Adju -

tant General, Subj: Military Characteristics of

Airplanes and Airships, Dec. 13, 1933.

OCAC, Correspondence, 1917–1938, 452.1

(Air Ambulances), RG 18, NARA, College

Park, hereinafter cited as NARA II.)

9. Memo, Westover for the Adjutant

Gene ral, Subj: Military Characteristics of

Air planes and Airships, Dec. 13, 1933. 2nd

Endorsement, SGO to Adjutant General, Jan.

17, 1934; 5th Endorsement, Adjutant General

to Chief of Air Corps, thru SGO, Feb. 15,

1934.

10. John F. Shiner, Foulois and the U.S.

Army Air Corps, 1931–1935 (Washington,

D.C.: Office of Air Force History, 1983), p.

109. According to Shiner, most fatalities

involved Reserve officers serving one year’s

active duty after completing flight training

with pilot training itself being the next highest killer.

11. According to Maj.C. L. Beaven, the

single-engine Fokker had a cruising speed of

115 mph, a top speed of 133 mph, and an

endurance of 41⁄2 to 5 hours, which translates

into between 517 and 575 miles at cruising

speed. It was soundproofed and had brakes to

shorten its landing run and shock absorbers

and extra large balloon tires to minimize the

jar on patients from landing. However, it

could carry only three litter patients, a flight

surgeon, and one sitting patient. Beaven,

“New Ambulance Airplane for U.S. Army

Air Corps,” The Military Surgeon 68 (June

1931): 777. According to the manufacturer,

the top speed was 140 mph, and it had a relatively short landing roll of 410 ft. in Army

tests. Ltr, V.E. Bertrandias, Asst. Gen. Mgr. of

Sales, to Maj. Benjamin Warriner,

Commander of the School of Aviation

Medicine, Dec. 30, 1930, Brooks

Aeromedical Archives.

12. Maj. C. L. Beaven, “First Air Division

(Provisional) Maneuvers,” The Military

Surgeon 69 (Aug. 1931): 133. Four other

transports that participated were committed

for conversion to air ambulance use as necessary during the maneuvers. Hap Arnold

served as the G–4, the logistics chief, responsible with Beaven, the maneuver surgeon, for

air transport and aeromedical evacuation of

“casualties.” Futrell, Development of

Aeromedical Evacuation in the USAF, 8.

13. Darby, “Airplane Ambulance

Evacuation,” 162–74. The title of Simpson’s

article was more specifically related to his

proponency, “The Airplane Ambulance–Its

Use in War,” 63, 35–48. The quote is from

Darby, p. 162.

14. Lecture, “Airplane Ambulance

Evacuation,” Medical Corps Course,

1931–1932, Air Corps Tactical School, File:

248.101-40A, USAF Historical Research

Archives, Maxwell AFB, Alabama, hereinafter cited as HRA.

15. Except as otherwise indicated, the discussion that follows is drawn from the Darby

and Simpson articles. The author of particular points discussed is identified in the text,

and formal footnotes containing specific

page numbers have been omitted in the interests of simplicity because each of the articles

is relatively short. 

16. Darby assumed squadrons of twentyone air ambulances organized into three

flights of seven, Simpson twelve to a

squadron organized into three flights of four.

Both assumed the capability of each aircraft

to evacuate eight patients on each flight.

17. For the CRAF and its role in aeromedical evacuation systems, see Chapter 10.

18. “Discussion by Captain W. E. Lynd,

Air Corps,” in Simpson, “The Airplane

Ambulance-Its Use in War,” p. 45.

19. Darby explicitly used the rates suffered during the Meuse-Argonne offensive of

329

Notes
1918; the source of Simpson’s estimates is

less clear, but a reasonable inference is that

they were based on World War I experience.

20. Lt. Col. G.P. Lawrence, “The Use of

Autogyros in the Evacuation of Wounded,”

The Military Surgeon 67 (December 1933):

314.

21. In his article describing the First Air

Division (Provisional) maneuvers for which

he had served as division surgeon, Beaven

had recommended that autogyros be considered for the small, two litter-capable crash

rescue-type vehicles that he believed necessary to complement the large, transport-type

aircraft that he reported had been used so successfully during the maneuvers. “First Air

Division (Provisional) Maneuvers,” 141.

22. Bauer’s paper, presented before the

37th Annual Meeting in Denver, Colorado,

was published as “The Development of

Commercial Aeronautics and of the Airplane

Ambulance,” The Military Surgeon 66 (Feb.

1930); for Bauer’s comment, see p. 170.

Bauer, one of the first flight surgeons, had

commanded the School of Aviation

Medicine, and in 1926, by authority of the

surgeon general, had published the first text

on aviation medicine. He founded the Aero

Medical Association in 1929 and, when he

presented the paper, he was the Medical

Director of Aeronautics for the U.S.

Department of Commerce.

23. See the Report of the Surgeon General

U.S. Army to the Secretary of War [Year]

(Washington, D.C.: United States Govern -

ment Printing Office, [Year]) for the years in

question. In conjunction with urging procurement of additional air ambulances, several

reports cite the number of medical evacuations accomplished: 103 during FY 1933;

139 including 73 members of the Civilian

Conservation Corps during FY 1934; and

103 during FY 1933. Procurement of one autogyro was recommended in the 1933 report.

24. Futrell, Development of Aeromedical

Evacuation in the USAF, 9–10.

25. For the Lyster episode, see Medical

Support of the AAF in World War II, 17–18.

Hiram Bingham, who served as chief of personnel for the Air Service of the AEF in

France and became a U.S. senator, describes

Pershing’s actions regarding flying pay in his

memoir of World War I: An Explorer in the

Air Service (New Haven: Yale University

Press, 1920), 221–22. The British and French

were providing flight pay to their aviators at

the time. Bingham also relates a number of

telling anecdotes describing the gulf that

arose between the AEF’s young pilots and the

nonflying regular officers who had been put

in charge of air units in the AEF. Large numbers of these, according to Bingham, made

no attempt to qualify as either pilots or

observers, or even to fly cross-country as passengers. One of the most graphic examples of

what lack of understanding such officers had

about flying concerns one, newly assigned as

commanding officer (CO) of one of the

largest flying schools, who after his first tour

of inspection issued a written order that there

should be “no more rough landings” because

the officer in charge of flying had told him

that cadets’ rough landings had caused the

destruction of several relatively new aircraft

that the new CO had observed on his tour. An

Explorer in the Air Service, p. 103. 

26. The original untitled review was published in the Aug. 1927 issue of the

Proceedings and occupied seven pages.

Reprinted in The Military Surgeon 59 (Oct.

1927), it occupied thirteen pages including a

one-page editorial entitled “Pessimism and

Aviation” by the editor of The Military

Surgeon. Further citations will be by page

number in the Proceedings reprint.

27. Harbord review, p. 481.

28. Harbord review, p. 484.

29. Harbord review, p. 487.

30. Harbord review, pp. 491–92.

31. Editorial, “Pessimism and Aviation,”

Harbord review, p. 480. Harbord was a graduate of the Army War College and a former

cavalryman who was noted for his intense

loyalty to his friend and former commander

330

Notes
in France, General John J. Pershing. Edward

M. Coffman, The War to End All Wars: The

American Military Experience in World War

I (New York: Oxford University Press, 1968),

p. 46.

32. Interview with Dr. Robert Joy,

Director of the Medical History Program,

Uniformed Services University of the Health

Sciences, and his deputy, Dr. Dale Smith, Jan.

18, 1996. A very interesting piece of corroborating contemporary evidence is a letter

from David Grant, the future first Air

Surgeon of the Army Air Forces, to Lt. Col.

C. L. Beaven, then Chief Flight Surgeon in

the Office of the Chief of the Air Corps, Oct.

14, 1939, in which Grant reminds Beaven of

the “old type” of flight surgeon “sitting on the

line, drinking most of the night, etc.” File

168.7248-4, HRA. A copy of the original letter to Beaven is also in General Grant’s personal papers, which are in the possession of

his son, David Grant, Jr. Mr. Grant, now

deceased, kindly allowed the author to use his

father’s papers in preparing this manuscript.

33. Maurer discusses the depression-era

budgets and sacrifices imposed on Army personnel in Aviation in the U.S. Army, 1919–

1939, pp. 346–47. To save additional money,

the new congress in 1934 also limited the

number of flight surgeons receiving flying

pay to five, thus prompting a repeated complaint in the section of the surgeon general’s

reports to the Secretary of War written by the

Air Corps medical section about the embarrassment and difficulties created by the limitation. See, for example, the reports for 1935,

1936, and 1937.

34. Rhoads’ article, some 125 pages in

total length, appeared in vol. 54, Feb. through

May, 1924; sources for the reference to “nontransportables” and consideration of airfield

availability in selecting new general hospital

sites are on pp. 411 and 522, respectively.

35. Maj. Thomas R. Goethals, “Some

Phases of Army Evacuation,” The Military

Surgeon 61 (Oct. 1927): 425–37. 

36. Beaven, “The Present Need for

Airplane Ambulances by the United States

Army” The Military Surgeon 75 (Sept.

1935): 146.

37. Perhaps primarily with an eye toward

justifying procurement of more transport aircraft, Arnold, then of the Air Corps, noted in

Dec. 1936 that, among other requirements,

more transports were needed for use as air

ambulances. Futrell, Development of

Aeromedical Evacuation in the USAF, p. 11.

As discussed earlier, Arnold had worked with

the exercise surgeon as the G–4 responsible

for air transport and aeromedical evacuation

during the First Air Division (Provisional)

maneuvers.

38. This section is heavily indebted to the

previous work of Dr. Robert E. Skinner, who

in 1983 published an article, “The Making of

the Air Surgeon: The Early Life and Career of

David N. W. Grant,” in Aviation, Space and

Environmental Medicine (ASEM), the journal of the Aerospace Medical Association

founded in 1929 By Louis Bauer. Skinner’s

article was based in large part on selected

portions of David Grant’s papers released to

Skinner by Grant’s son, who supplemented

this information with his own memories of

life at Randolph Field and contact with his

father during World War II when the younger

Grant was also in the Army Air Forces.

However, Mr. Grant did not release major

portions of his father’s typed diary to Skinner

because he deemed them too frank in their

appraisal of certain officers still living with

whom his father had served during World

War II. More than a decade having passed,

Mr. Grant was kind enough to provide the

author full access to his father’s papers, and,

moreover, provided his full cooperation in

preparing this part of the manuscript. For

convenience, Skinner’s article is cited as the

source occasionally even though the document upon which he bases his text has been

viewed by the author. In these cases,

Skinner’s footnotes can cue the scholar to the

proper document in the Grant papers. These

are presently in the custody of the author, but

331

Notes
Mr. Grant indicated he wished ultimately to

deposit them in the USAF Academy’s

Library Special Collection, a desire affirmed

by Mr. Grant’s widow.

39. “The Air Corps Training Center,” Air

Corps Newsletter XXII (Aug. 1939), 8.

Skinner, “The Making of the Air Surgeon,”

79. Grant’s request for assignment to duties

as a flight surgeon had been forwarded to the

surgeon general’s office recommending

approval with the further recommendation

that Grant be considered for assignment to

Randolph as an additional flight surgeon to

meet the requirements for expansion at that

field. 2nd Endorsement, G. I. Jones, Chief,

Medical Division, OCAC, to SG, Apr. 29,

1931, File of Personal Orders, Grant papers.

40. Shiner, Foulois and the U.S. Army Air

Corps, p. 113. Grant’s flight time is from

Skinner, “The Making of the Air Surgeon,” p.

24.

41. Grant’s File of Personal Orders for the

period shows numerous navigation flights,

many of which were flown with the future

general officers, Joe Cannon and David

Schlatter. Grant papers.

42. Grant’s son related an anecdote drawn

from the family’s time at Randolph when the

then junior officer, Hoyt Vandenberg, USAF

Chief of Staff, 1948–53, was almost killed

during filming of a motion picture set at

Randolph. Interview by the author, Feb. 2,

1996.

43. S.O. 72, War Department, Mar. 25,

1936, File of Personal Orders, Grant papers.

44. Andrews, in his report of the goodwill

flight to the Canal Zone for which Grant had

served as flight surgeon, remarked that Grant

“had the proper temperament for this type of

duty...and was always cheerful and alert.”

See fn. 41. According to Grant’s son, who

was a teenager during his father’s assignment

to Randolph, the elder Grant was always very

popular with the Air Corps people, some of

whom had previously had bad experiences

with flight surgeons. Grant could recall no

specific examples of the latter, basing his

comments on impressions gathered during

dinner table conversation at the time.

Conversation with the author, May 20, 1996.

Ltr to Grant from the Adjutant General, Subj:

Qualifications for Promotion, Sept. 24, 1936.

File of Personal Orders. Grant papers.

45. The ACTS was self-consciously radical, advertising “the new vistas” that it had

opened for officers attending its courses, and

affirming the “substantiation” of the doctrine

of airpower that had been provided by new

types of aircraft as early as 1925, obviously

something with which not just General

Harbord would have disagreed.” The doctrine of daylight precision bombardment provided a specific means to achieve the destruction of an enemy’s “vital establishments,”

which the school asserted was the “new mission of the military aviation forces. “The Air

Corps Tactical School,” Air Corps News

Letter XXII (Aug. 1, 1939): 9.

46. The best brief study of the ACTS is

still Robert T. Finney, History of the Air

Corps Tactical School, 1920–1940 (Wash -

ing ton, D.C.: Center for Air Force History,

1992), reprint of a study first published in

1955. The 1939 curriculum is detailed in

“The Air Corps Tactical School,” Air Corps

News Letter XXII (Aug. 1, 1939): 13.

47. Grant, “The Value of the Autogyro in

Military Operations,” Thesis, U.S. Air Corps

Tactical School, Maxwell Field, Ala. (May

10, 1937), pp. 8–9.

48. Grant diary, entry for Mar. 5, 1942.

Grant papers.

49. Hume, “The International Congress

of Military Medicine and Pharmacy,” p. 35.

However, the United States did not fund an

official delegation to the 1933 Congress (p.

36). James M. Phalen, “Chiefs of the Medical

Department, United States Army,

1775–1940. Biographical Sketches,” The

Army Medical Bulletin 52 (Apr. 1940): 105.

“Third International Congress on Sanitary

Aviation,” The Army Medical Bulletin 33

(Oct. 1935): 67.

50. Lt. Col. Ernest F. Harrison,

332

Notes
“Evacuation of Sick and Wounded by Air”

(Oct. 1937): 36–37. D. Palma, “L’aviation

sanitaire de l’U.R.S.S.,” Comite international de la Croix-Rouge, LXVIII (Apr. 1937):

520–21. “Launching of an Air Ambulance,”

Monthly Bulletin of the League of Red Cross

Societies XVII (July 1936): 107; “First

International Technical Conference on Aerial

Relief,” XIX (Aug. 1937); “The Third

International Air Ambulance Congress,” XVI

(Jan. 1935): 13.

51. “The School of Aviation Medicine

Exhibit,” Air Corps News Letter XXII (15

June 1939): 3. Hippke, in an article published

in 1940, which will be discussed later, mentioned a 1936 article in Der deutsche

Militararzt in which he urged the need for

large transport aircraft to evacuate sick and

wounded rather than the usually small specially designed air ambulances that were usually seen at international exhibitions.

“Transport by Air of the Sick and Wounded,”

The Military Surgeon 86 (May 1940): 439.

52. E. Evrard, “Les premieres evacuations sanitaire par air a la Force aerienne

belge,” Acta Belgica Historiae Medicinae

1:3–4 (1988): 26. 

53. Skinner, “The Making of the Air

Surgeon,” p. 80.

54. Grant diary entry for Sept. 30, 1939.

Grant papers.

55. Grant diary entry for Sept. 30, 1939.

Grant papers.

56. Grant diary entry for Oct. 2, 1939.

Grant papers.

57. The flight surgeon episode was

described to Beaven in a very frank letter

from Grant of Oct. 14, 1939. Grant papers. A

copy is in File 168.7248-4, HRA. This

episode and that concerning the attempt by

Reynolds and his successor, James McGee,

are treated in Link and Coleman, Medical

Support of the AAF in WWII, pp. 24–35.

58. Link and Coleman, Medical Support

of the AAF in WW II, pp. 359–60.

59. Hippke, “Transport by Air of the Sick

and Wounded,” The Military Surgeon 86

(May 1940): 439–44; Colonel Staff Inspector

Hans Kowalzig, Medical Air Services,

German Army, “Long Distance

Transportation of the Wounded by Air at

High Altitudes,” The Military Surgeon 86

(June 1940): 565–71; Staff Surgeon Dr. W.

Tonnis, Consultant on Staff, Chief of Medical

Service, German Air Force, “Air

Transportation of the Sick and Wounded: A

Medical Problem,” The Military Surgeon 87

(July 1940): 23–25; Staff Surgeon Frederick

Schmidt, Chief Flight Surgeon, German Air

Force, “Transportation of the Wounded by

Plane,” The Military Surgeon 87 (Aug.

1940): 137–41. Colonel Harold W. Jones,

from the Army Medical Corps, edited all four

articles, three of which were translated by

Regina K. Plavsky, Hippke’s by Beatrice

Bickel, who was herself an M.D.

60. Quotation is from Link and Coleman,

Medical Support of the AAF in WW II, p. 360.

Although Link and Coleman also discuss the

evolution of the first air ambulance units, the

treatment by Clarence McKittrick Smith in

his volume in the United States Army in

World War II seems somewhat clearer: The

Technical Services: The Medical

Department: Hospitalization and

Evacuation, Zone of Interior (Washington,

D.C.: Office of the Chief of Military His -

tory,1956), pp. 438–39.

Chapter Three

1. Wesley Frank Craven and James Lea

Cate, eds., The Army Air Forces in World War

II, Vol. VI, Men and Planes (Chicago,

University of Chicago Press, 1955), p. xv.

2. Irving B. Holley, The U.S. Army in

World War II. Buying Aircraft: Materiel

Procurement for the Army Air Forces

(Washington, D.C.: Office of the Chief of

Military History, 1964), p. 557.

3. Holley, Buying Aircraft, p. 16.

4. Robert F. Futrell, Ideas, Concepts,

Doctrine: Basic Thinking in the United States

Air Force, 1907–1960, Vol. I (Maxwell AFB,

333

Notes
Ala.: Air University Press, December, 1989),

p. 178.

5. Charles E. Miller, Airlift Doctrine

(Maxwell AFB, Ala: Air University Press,

1988), pp. 79–81.

6. In separate interviews several years

after the war’s end, both Maj. Gen. Howard

McC. Snyder, a Medical Corps officer who

had served as Deputy Army Inspector

General, and Tracy Voorhees, former head of

the control division in the surgeon general’s

office, stated that this was the original purpose of the committee investigation. Each

was in a position to know, particularly Snyder

who inspected medical facilities worldwide

and was almost certainly the “Medical general officer in the Inspector General’s

Department” who General Marshall said he

had placed there to keep an eye on the medical department. A lawyer by training,

Voorhees was commissioned in the Judge

Advocate General’s Corps but, after assignment to the office of the surgeon general

(SG), he became the SG’s “troubleshooter,”

and, among other things, corrected serious

deficiencies in the medical supply system in

both the Pacific and European theaters on the

surgeon’s behalf. Blanche B. Armfield,

Medical Department, United States Army:

Organization and Administration in World

War II (Washington, D.C.: Office of the

Surgeon General, 1963), p. 185, fn 69, p. 200.

Voorhees repeated this charge in a candid

unpublished memoir written just at the end of

the war: “Recollections of My Work for the

Surgeon General,” Oct. 1945, unpublished

typescript, Tracy Voorhees papers, Special

Collections, Alexander Library, Rutgers

University. Somervell drafted a letter to

President Roosevelt in Apr. 1943 in which

Secretary Stimson expressed his “complete

dissatisfaction with the present incumbent,

and the lack of confidence in him on the part

of the high command, and the almost universal condemnation of his work by the profession.” Secretary of War’s TS Files, box 13,

RG 107, NARA II.

7. “Report of the Committee to Study the

Medical Department of the Army,” Nov. 24,

1942. Records of the Historical Division,

ASF, box 487, RG 160, NARA II. Armfield,

Organization and Administration of the

Medical Department, devotes an entire chapter to the Wadhams Committee; Chapter V,

pp. 45–85. Because of the recommendation

of the committee regarding the AAF, Magee

was never given a full copy of the report,

although given the presence of two senior

retired medical department officers on the

committee who were sympathetic to his surgeon general’s office were finally given a

copy in the late 1940s.

8. Copies were even built under license

by the Soviet Union, which also received

large numbers of C–47s under Lend-Lease.

9. Holley, Buying Aircraft, p. 551; F. G.

Swanborough, U.S. Military Aircraft since

1909 (New York: Putnam, 1963), pp.

221–22. Holley cautions that the figures in

the table from which these procurement numbers were taken include all acceptances by

the AAF including those aircraft afterward

transferred under Lend-Lease. The fact

remains that very large numbers were procured and used widely throughout the combat

theaters.

10. These aircraft are discussed in more

detail in Chapter 4.

11. For a full discussion of ATC origins

and development, see Craven and Cate, AAF

in WW II, Vol. I, Plans and Early Operations

(Chicago: University of Chicago Press,

1948), pp. 349–65.

12. Hqs., AAF, General Orders [GO] 8,

June 20, 1942; also quoted in Craven and

Cate, AAF in WW. Plans and Early

Operations. The GO also redesignated the

existing “Air Transport Command” as the”

Troop Carrier Command” with the primary

mission of any troop carrier units identified

as to “provide transportation for parachute

troops, air-borne infantry and glider units.”

Arnold had created the earlier Air Transport

Command in Apr. 1942 to take over the Air

334

Notes
Service Command’s ATGs.

13. “Inferentially,” because a review of

reports on relevant experiments conducted at

the Aeromedical Laboratory at Wright Field

prior to the war specifically extrapolates in

only one case the results from a healthy subject who had undergone stress induced by

conditions encountered inflight to a sick or

wounded patient. Air Corps, Materiel

Division, Memo Report EXP-M-54-653-27,

Subj: The Effect of Decreased Barometric

Pressure on the Electrocardiogram, Oct. 25,

1940, recommended “that all cardiac patients

transported by air receive oxygen by inhalation throughout the flight.” Aeromedical

Laboratory Archives, Scientific and

Technical Information Office (STINFO),

Wright Field, Ohio.

14. In Aug. 1943, the War Department

published the evacuation policy for overseas

commands as: 180 days for the European theater, less Icelandand the CBI theater; and 120

days for all other overseas theaters, defense

commands, department, and separate bases.

Memo No. W40-19-43, The Adjutant

General, “Policy on Evacuation of Sick and

Wounded from Overseas Commands,” Aug.

28, 1943. Office of the CG, ASF, Control

Division, Special Reports, 1942–46, box 487,

RG 160, NARA II.

15. In Mar. 1941, Grant published an article, “Airplane Ambulance Evacuation,” in

The Military Surgeon (88:3) that described a

proposed air ambulance battalion that incorporated the elements of the later T/O. The

historian of hospitalization and evacuation in

the ZI by the U.S. Army during World War II

is neutral on the issue, citing “collaboration”

between the surgeon general and the Air

Corps medical division in developing an

agreed concept for such an organization and

its mission. Link and Coleman, Medical

Support of the Army Air Forces in World War

II, p, 360. Charles McKittrick Smith, United

States Army in World War II. The Technical

Services. The Medical Department:

Hospitalization and Evacuation, Zone of

Interior (Washington, D.C.: Office of the

Chief of Military History, 1956), pp. 438–39.

Grant diary, entry for Sept. 15, 1942. Grant

papers.

16. The Air Force Combat Command was

formed in June 1941 by the integration of the

four numbered Air Forces and their bases into

a single organization and represented a further evolution of the consolidation of Air

Force capability and centralization of control

begun by formation of the General

Headquarters Air Force in 1935. Craven and

Cate, AAF in WWII. Services Around the

World, pp. 154–55. For a full discussion of

the GHQ Air Force, see Maurer, Aviation in

the U.S. Army, 1919–1939, pp. 319–43.

17. Oral History, Maj. Gen. (Ret.)

Richard L. Meiling, USAF MC, Oct. 25–28,

1982, pp. 49–51. USUHS Library. Meiling

later served on the United States Strategic

Bombing Survey, became Deputy Secretary

of Defense in Charge of Medical and Health

Affairs after the war in the Truman administration, and Dean of the Ohio State

University School of Medicine in 1961.

18. Swanborough, United States Military

Aircraft since 1909, pp. 215–16, 221–27.

19. Mss., David Grant, “Airplane

Ambulance Evacuation,” p. 10. Grant papers;

published in The Military Surgeon 88 (Mar.

1941), 238–43. That the air ambulances were

to be painted in accord with the Geneva

Convention was clearly the understanding of

the Director of Military Requirements. See

Muir Fairchild quote on p. 22.

20. “Airplane Ambulance Evacuation,” p.

12. Frederick R. Guilford and Burton J.

Soboroff, “Air Evacuation: A Historical

Review,” Aviation Medicine, 18 (1947):

601–606. Although this article is much cited,

Guilford and Soboroff do not footnote their

article. The three most scholarly published

sources–Futrell, Link and Coleman, and

Clarence McKittrick Smith–differ in a number of particulars, with Smith presenting the

most clear and convincing account of the

process leading to T/O 8–437, although his

335

Notes
use of passive voice tends to obscure the less

than enthusiastic role played in this process

by the surgeon general. The account that follows is a synthesis that also draws on other

sources, which are cited.

21. Smith, Hospitalization and

Evacuation, ZI, pp. 437–38.

22. Futrell, Development of Aeromedical

Evacuation in the AAF, p. 20.

23. Link and Coleman, Medical Support

of the AAF in WW II, p. 50.

24. Although this account is totally consistent with the personalities of the protagonists and their respective attitudes toward

using aircraft for casualty evacuation, it does

not appear in the well-documented account

of Clarence McKittrick Smith. Link and

Coleman do not footnote a source for their

account, but, on the basis of internal evidence, it would appear to have been based

upon interviews long after the event. Their

volume is comprehensive and obviously

based upon extensive research, but it contains

occasional errors of fact that suggest a certain

degree of caution should be exercised when

reading it. For example, the Air Corps never

had more than two Cox-Klemins (not three

“Klemum”) air ambulances. Additionally,

although Richard Meiling was extremely

important in the development of aeromedical

evacuation during the war, he was not as they

assert the “first and only Air Evacuation

Officer in the Office of the Air Surgeon,” Col.

Wood S. Woolford having been so designated by Grant in Nov. 1942. 1st Ind., Nov. 16,

1942, signed by Grant, to Memo for CG,

AAF (Attn, Air Surgeon) from Col. F.A.

Heil eman, Dep. Asst. Chief of Staff for

Opera tions, SOS, Subj: Evacuation Opera -

tion, Nov. 9, 1942. CDF 1942-1944, 370.05,

Evacuation, box 505, RG 18, NARA II.

25. Smith, Hospitalization and Evacua -

tion, ZI, p.438. Futrell, Development of

Aeromedical Evacuation in the USAF, p. 20.

Link and Coleman state that the AAF had

activated the 38th, but the general order was

issued by Headquarters Third Army, San

Antonio, Tex. Medical Support of the AAF in

WW II, pp. 366, 412, note 8. Grant noted in

his diary on Nov. 12, 1942, that the unit at

Fort Benning “now under the Surgeon

General” was ready to be transferred to

Bowman Field in accordance with tentative

approval of Grant’s Air Evacuation Plan by

the War Department General Staff. 

26. Futrell, Development of Aeromedical

Evacuation in the AAF, p. 20.

27. Ibid. Training Bulletin, Conversion of

C–46 & C–47A to Air Evacuation Plane

(Bowman Field, Kentucky: Army Air Forces

School of Air Evacuation, Aug. 15, 1943).

These were Evans litter supports, presumably

named after the designer. Grant’s recommendation specifically ruled out the more bulky

Navy-designed Stokes litter that had been in

use for many years and that was essentially a

wire basket.

28. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 20. Flight

Surgeon’s Reference File (Randolph Field,

Tex.: AAF School of Aviation Medicine,

Nov. 1945), p. 4-3-7. Futrell states that the

metal brackets, when installed, provided a litter capacity of only thirteen, but this is contradicted by the Reference File, which also

states that metal brackets were installed on

only a few C–54As. The issue of litter installation devices was addressed by the

Aeromedical Laboratory at Wright Field,

which developed and tested strap assemblies

and solved the problems of lost litter bracket

parts, weight of the installations, and the use

of aluminum (which was a critical material).

Link and Coleman, Medical Support of the

AAF in WW II, pp. 296–97.

29. Portions of the Special Orders are

quoted in Grant diary, entry for Oct. 30, 1941.

Grant papers.

30. Futrell quotes Woolford as writing in

Feb. 1943, after an inspection of the North

African front that he saw no requirement for

nurses to accompany patients in flight in the

North African theater because of the short

flight times and the shortage of nurses.

336

Notes
Futrell, Development of Aeromedical Evacu -

ation in the AAF, p. 24. Meiling was not yet

assigned to the Air Surgeon’s office and, in

any event, makes no claim to having proposed the use of nurses in his oral history

memoir. In the absence of other proof and in

light of Grant’s strong support of the flight

nurses throughout the war, a reasonable conjecture may be that he suggested the idea to

Woolford as an element he should include in

the plan. However, Link and Coleman note

that “the Chief of the Medical Division,” in

July 1940, opined that he did not believe

“that in time of war, as a routine measure,

nurses will be used on airplane ambulances.”

Although they do not name the author of the

quotation, merely citing his position, the

chief of the medical division at that time was,

of course, Grant. Link and Coleman, Medical

Support of the AAF in WW II, p. 370; note 33,

p. 413.

31. Futrell, Development of Aeromedical

Evacuation in the AAF, p. 24. Smith, Hospi -

tal ization and Evacuation, ZI, p. 439.

32. Futrell, p. 32. Development of

Aeromedical Evacuation in the AAF, pp.

24–25. Smith, Hospitalization and Evacua -

tion, ZI, 439. Grant diary entry for Nov. 16,

1942. Grant papers. 1st Ind., Nov. 16, 1942,

Memo for CG, AAF (Attn, Air Surgeon) from

Col. F.A. Heileman, Dep. Asst. Chief of Staff

for Operations, SOS, Subj: Evacuation

Operations, Nov. 9, 1942.

33. Grant diary entries for Aug. 7, Sept.

12, Oct. 16–17, 18–28, 1942. Grant papers.

34. Routing and Record Sheet, Comment

#1, CG, Air Materiel Command, to

Movements and Operations Division, Aug.

16, 1942. CDF, 1942–44, 452.1 Ambulance

Planes, box 1231 RG 18, NARA II.

35. 1st Ind. [basic Ltr unknown], Mar. 8,

1943, CG, AAF Flying Training Command,

to CG, AAF. CDF, 1942–44, 452.1, box 1231,

RG 18,. Ltr, Dec. 16, 1943, CG, AAF

Western Technical Training Command, to

CG, Central Flying Training Command,

Subj: Procurement of Airplane Ambulance.

CDF. 452.1, box 1209. Ltr, Commandant,

Field Artillery School, Ft. Sill, Oklahoma, to

CG, Replacement and School Command,

Army Ground Forces (AGF), Mar. 13, 1943.

CDF, 1942–44, 452.1, Ambulance Planes,

box 1209, RG 18, NARA II.

36. Ltr, Commandant, Field Artillery

School, Ft. Sill, Oklahoma to CG, Replace -

ment and School Command, AGF.

37. 3rd Ind. (basic memo unknown),

Conversion of Liaison Type Airplanes, Oct.

30, 1942, Col. David A. Schlatter, Division of

Ground Support. CDF 1942–44, 452.1, box

505, RG 18, NARA II.

38. 4th Ind. (basic memo unknown), Oct.

31, 1942, to Director of Training, CDF

1942–44, 452.1, box 505, RG 18, NARA II.

39. 4th Ind. (Basic memo unkown)

Conversion of Liaison Type Airplanes, Oct.

31, 1942. The Navy Piper, designated the

HE–1, had been championed by Maj. Victor

Frazier, a flight surgeon assigned to Army

Field Artillery School at Fort Sill, Okla., but

it was evaluated by the Office of the Air

Surgeon (OTAS) as too limited because only

a Stokes litter could be used with it and the

aircraft was underpowered. Memo, to the

CG, ASF, for the Surgeon General, Sept.

1943, Subj: Air Evacuation by Light

Airplane; 6th Ind., Colonel H.C. Chenault,

OTAS, to CG, ASF, Oct. 6, 1943. CDF

1942–44, 452.1, box 505, RG 18, NARA II.

40. Futrell, Development of Aeromedical

Evacuation in the AAF, p.25.

41. Arnold had asked Stratemeyer “what

is your plan to evacuate the wounded?” to

which Stratemeyer had responded that “all

theaters had transports which carry supplies

enroute and that they could well return the

wounded.” Interestingly, Stratemeyer could

not answer Arnold’s question whether the

AAF’s transports could take litters or not, but

Arnold stipulated that, if this could be done,

he would support retrograde movement as

the way of evacuating the wounded. 1st Ind.

[basic Ltr unknown, Subj: Conversion of

Airplanes to Evacuate Wounded], Strate -

337

Notes
meyer to General Fairchild, Director of

Military Requirements, Nov. 12, 1942.

Quotes are from the Stratemeyer, CDF,

370.05, Evacuation, box 505, RG 18, NARA

II.

42. Military Requirements Policy N. 41,

Subj: Ambulance Airplanes for Evacuating

Wounded by Cargo Airplanes, May 25, 1943.

CDF, 1942–44, 370.05, Evacuation, box 505,

RG 18, NARA II.

43. Military Requirements Policy N. 41,

subj: Ambulance Airplanes for Evacuating

Wounded, May 25, 1943.

44. Ibid.

45. Ibid.

46. R & R, Subj: Ambulance Airplanes,

Comment 7, AFROM TO AFRIT thru

AFAMC, Oct. 22, 1942. RG 18, CDF,

1942–44, 452.1 Airplanes (Misc.), box 1231,

NARA II. No aircraft had been allocated to

the Flying Training Command, and the first

C–64 was not to be delivered until the following month.

47. The “puddle jumper” reference is in R

& R, Subj: Conversion of Airplanes to

Evacuate Wounded, Comment 2, AFDMR

TO AFRAS (Attn Colonel Weyland), Nov.

14, 1942. CDF, 1942–44, 370.05, Evacua -

tion, RG 18, NARA II.

48. World War II Flight Nurses

Association, The Story of Air Evacuation,

1942–1989 (Dallas, Tex.: Taylor Publishing

Company, 1989),. p. 7. Smith, Hospitaliza -

tion and Evacuation, ZI, p. 439. Smith states

a figure of eight enlisted men per flight, six

medical technicians, and two administrative

specialists to allow a certain administrative

autonomy to a flight.

49. Gen. Doolittle, who would command

the 12th Air Force in North Africa, had asked

for two Evacuation Groups according to

Grant diary entry, Oct. 18–28 1942. Grant

papers.

50. Grant diary entries, Sept. 15 and 17,

and Sept. and Oct. 16 and 17, 1942. Grant

papers. Candidates for admission to the Army

nurse corps prior to the war were vetted by

the Red Cross, and were all women. There

was, of course, no draft for women during the

war.

51. Margaret Richey Raffa, Matilda

Grinivech, and Samuel Amirato, “History of

the 801st MAES,” Clara Morrey Murphy,

Dottie Lonergan Jouvenat, Harold Carter, et

al., “History of the 802 MAES,” and Dr.

Goeffrey P. Weidenmen, “History of the 804

MAES,” in The Story of Air Evacuation

1942–89 (Dallas, TX: Taylor Publishing

Company, 1989), pp. 70–72, 73. The authors

of the brief unit histories and related information in this book were all members of the

units discussed. I am indebted to a number of

the associations’ members, particularly Col.

(Ret.) Murphy and Lt. Col. (Ret.) Raffa, who

was the Chief Nurse of the first MAETS, the

801st, which was also the first deployed

overseas for their personal recollections.

52. As Grant’s son was to put it many

years later, it was the fact that his father

proved to Arnold that he was an Air Force

officer first and a doctor second–that is, that

he believed that the Air Force Medical

Service was there to support the Air Force

mission–that made Arnold trust him completely. Conversation with David Grant, Jr.,

Sept. 3, 1996. For a discussion of the ASF’s

attitude, see John Millett, United States Army

in World War II. The Army Service Forces:

The Organization and Role of the Army

Service Forces (Washington, D.C.: Center of

Military History, 1987), pp. 132–33.

53. For example, see Chapter IX, “The

Somervell Proposals for War Department

Reorganization” of Millett, Organization and

Role of the Army Service Forces.

54. Millet, Organization and Role of the

Army Service Forces, p. 7. War Department

Circular 59, “War Department Reorganiza -

tion,” Mar. 2, 1942. Office of the Air Sur -

geon, Executive Office, Historical Branch,

Correspondence and Reports, 1940–46, box

2, RG 18, NARA II. The circular specified

that the reorganization would take effect on

Mar. 9, 1942.

338

Notes
55. Ltr, Sept. 12, 1943. Hawley–Kirk

Correspondence. Refiles from the U.S. Army

Center for Military History (War Department

Decimal Filing system), 014 Public Health

thru 121.6 Supply Costs, box 2, RG 112,

NARA II.

56. According to Gramt’s diary, Arnold

agreed with Grant’s decision because of the

position of the surgeon general’s office in the

War Department organization but thought it

would have been a good move if the surgeon

general reported directly to General

Marshall. Grant also told Arnold that he

wanted to avoid the politics of the selection

and had planned an inspection trip to the

Pacific so that he would be out of town while

it was being made. Entry for Mar. 5, 1943.

Grant had been approached the previous

November by a civilian doctor friend who

told him over lunch at the prestigious

Cosmos Club in Washington that he, Grant,

had been mentioned as a candidate to succeed Magee and had the support of the

American Medical Association as well as

many influential doctors. Entry for Nov. 7,

1942. Grant diary. Grant had received one

unsolicited testimonial regarding his qualifications to be the surgeon general in the form

of a letter from his former clerk who wrote to

President Roosevelt in May 1943 highly recommending Grant as “a leader, a man with

initiative, a man with brains and experience.”

Ltr, William Chudnovsky to President

Roosevelt, n.d. [stamped May 14, 1943, by

the administrative assistant]. Original in

Grant papers.

57. For example, when Eisenhower was

appointed to command the invasion of

Europe, he supported Spaatz to be the top

U.S. airman on his staff vis-à-vis Gen. Ira

Eaker. Richard G. Davis, Carl A. Spaatz and

the Air War in Europe (Washington, D.C.:

Center for Air Force History, 1993), p. 278.

Also see Eisenhower’s letter to General

George Marshall of June 26, 1942, regarding

how his senior commanders, including

Spaatz, are working “enthusiastically” and

agree with him on the attributes that the U.S.

army in Europe must exemplify in order to be

successful. Quoted in Joseph P. Hobbs, Dear

General. Eisenhower’s Wartime Letters to

Marshall (Baltimore: The Johns Hopkins

Press, 1971), p. 26. Finally, Spaatz and Omar

Bradley were the first two general officers in

his theater that Eisenhower recommended for

promotion. Russell F. Weigley, Eisenhower’s

Lieutenants. The Campaign of France and

Germany, 1944–1945 (Bloomington, Ind.:

Indiana University Press, 1990), p. 670. As

for Kenney, the mere fact that he survived for

the duration of the war as MacArthur’s air

commander after the Air Corps veteran and

former Chief of the Air Corps, George Brett,

was essentially fired says a great deal in

itself. However, Kenney more than survived;

he became perhaps MacArthur’s closest confidant, according to MacArthur’s most recent

biographer. Geoffrey Perret, Old Soldiers

Never Die: The Life of Douglas MacArthur

(New York: Random House, 1996), p. 340.

As noted previously, Spaatz requested two

aeromedical evacuation groups to support

Operation Torch in Oct. 1942.

58. Chapter 2 for Patterson’s proposal.

Christopher R. Gabel, The U.S. Army GHQ

Maneuvers of 1941 (Washington, D.C.: Cen -

ter of Military History, 1992), pp. 46–47.

Although casualties were generally assessed

by umpires who did not require evacuation,

Gabel indicates that some troops were designated to give evacuation squads practice.

Whether they were simulated or actual casualties of accidents, there were apparently long

lines of evacuees waiting for ground transportation. Link and Coleman, Medical

Support of the AAF in WW II, pp. 360–61.

59. Link and Coleman, Medical Support

of the AAF in WWII, p. 360.

60. Futrell, Development of Aeromedical

Evacuation in AAF, p. 25.

61. Grant diary entry for Sept. 15, 1942.

Grant papers.

62. Pers. Ltr, Tyng to Hawley, Oct. 18,

1942. Hawley–Kirk Correspondence. Tyng

339

Notes
was not an admirer of the Army’s airmen and

was somewhat vindictive. He began matterof-factly “as you know, in America the Air

Corps is hanging by the slenderest thread to

the War Department.” Tyng was convinced

that the supplies Grant was sending were

from stocks he had agreed to issue to AAF

depots only for use in emergency situations.

As punishment for the AAF “not playing the

game,” Tyng proposed on his own to sharply

reduce the amount of supplies made available

to AAF depots. He also tried to get Hawley to

send an official communication through Maj.

Gen. John C. Lee, commander of SOS in the

ETO, to Eisenhower so that an official protest

against “this pernicious practice” could be

lodged with General Marshall. Eisenhower

had been appointed ETO commander in June

1943, and directed to mount Operation Torch

in September. Torch was launched on Nov. 8,

and given the date of Tyng’s letter, it seems

probable that the colonel may not have

known about the invasion of North Africa. If

he did, he seems obtuse. See Stephen E.

Ambrose, Eisenhower: Soldier, General of

the Army, President-Elect, 1890–1952 (New

York: Simon and Schuster, 1983), pp.

182–88, and 201–07 for Eisenhower’s

intense activity regarding Torch at this time. 

63. Grant read the letter to the Wadhams

Committee during his testimony and left a

copy to be placed in the record. Grant diary

entry for October 18–28, 1942. Grant papers.

Ltr, Hawley to Tyng, November 7, 1942.

Hawley–Kirk Correspondence.

64. Voorhees, “Recollections of My Work

for the Surgeon General,” pp. 1–2. Voorhees

papers. Browning was himself commissioned from a senior position in private business to put procurement on a more businesslike basis. Millet, Organization and Role

of the ASF, p. 193.

65. For example, Grant diary entries for

Sept. 9, 16, 24, and 26, 1942. Grant papers.

Meiling Oral History interview, pp. 65–66.

Meiling remarks at dedication of David

Grant Medical Center. Grant papers. The idea

of co-opting Grant by offering him a position

as Deputy Surgeon General for Air had

apparently been discussed by Somervell in

Sept. 1942. Kirk’s direct offer came after his

selection in mid-1943.

66. Memo, Marshall for Arnold, Nov. 28,

1944. Arnold saw this as an attempt to take

away some of the Air Surgeon’s responsibilities and freedom, and he instructed Grant’s

deputy to prepare a good reason for turning

down Somervell’s proposal. Annotation on

copy of the memo. Grant papers. Grant

learned about the attempt only on his return

from the Pacific, and he commented to his

diary, “Kirk is evidently using every means to

get rid of me.” Grant diary entries for Nov. 30

and Dec. 1, 1944. Grant papers.

67. Some 1,300 casualties, sick and

wounded, were evacuated during the first

seventy days of the campaign on one-hour

flights over the mountainous, jungle-covered

interior. Link and Coleman, Medical Support

of the AAF in WW II, p. 361.

68. The Australian Air Force brought

experience using air ambulances to evacuate

wounded from service under British commanders in Egypt and North Africa. “Air

Evacuation of Casualties,” Tab D, p. 1.

Brigadier General Charles R. Glenn, Report

of Mission to Theaters, to CG, AAF (Atten -

tion: Air Surgeon), July 22, 1944. OTAS,

Exec. Office, Hist. Br., Correspondence &

Reports, box 2, RG 18, NARA II. This document was a plan for organized air evacuation

using the trained personnel of the then recently arrived first MAETS in MacArthur’s theater. It had been prepared by the commander

of the 804th MAETS and a group of flight

surgeons at the direction of “command.”

Whether the reference was to MacArthur’s

staff or Kenney’s is not clear.

69. Charles M. Wiltse, U.S. Army in World

War II. The Medical Department: Medical Ser -

vice in the Mediterranean and Minor Theaters

(Washington, D.C.: Center of Military History,

1989), 139. Futrell, Develop ment of Aero -

medical Evacuation in the AAF, p. 42.

340

Notes
70. “Notes Submitted by Brig. Gen. C.R.

Glenn,” Tab I, “Personal Diary,” p. 20.

Glenn, Report of Mission to Theatres, July

22, 1944. In his notes, Glenn stated that the

surgeon at the headquarters of the U.S. Army

Forces in the Middle East had expressed his

belief that movement by air was the only

method to move certain patients but they

could not get the British to take patients with

psychoneuroses from his hospitals. Glenn

“Personal Diary,” p. 16.

71. Grant diary entry for Nov. 19, 1944.

Grant papers. Grant told MacArthur of this

reluctance, and MacArthur seemed surprised

and said he would get orders out immediately to use aeromedical evacuation whenever it

was available. Maj. Gen. David A. Grant,

Report on Special Mission, to CG, AAF

(Thru: CG, Far Eastern Air Force, CINC,

Southwest Pacific Area [MacArthur], Nov.

23, 1944. Grant papers. Grant sent his report

through Kenny and MacArthur to Arnold

who had sent him to the theater to investigate

reports of morale problems with AAF personnel. The problem at Tacloban may have

had something to do with the difficulties of

airfield and hospital construction on Leyte.

See M. Hamlin Cannon, Leyte: The Return to

the Philippines (Washington, D.C.: Center of

Military History, 1996), pp. 192–94.

Interestingly, Cannon, who knew Grant from

their days together at Randolph Field in the

early 1930s, makes no mention of evacuation

by air in his discussion of casualty evacuation

on the cited pages.

72. The letter of recommendation that

Marshall sent to the Secretary of War stressed

that the selectee should have wide military

experience and the ability to organize a “widespread and complex military Medical service”

and preferably should have had actual battle

experience. Memo for the Secretary of War

from the Chief of Staff, Subj: Appointment of

Surgeon General, Feb. 21, 1943. Sec War TS

File, box 13, RG 107, NARA II.

73. Marshall almost certainly knew

Kenner in France because Marshall was

Director of Operations for the U.S. First

Division, which conducted the attack at

Cantigny in May 1918, during which Kenner

earned a Silver Star for gallantry. Forrest C.

Pogue, George C. Marshall: Education of a

General, 1880–1939 (London: MacGibbon

& Kee, 1964), pp. 184–85. Memo for Sec -

retary of War from Marshall, Subj: Appoint -

ment of Surgeon General, Feb. 21, 1943. The

recommendations from Patton and

Eisenhower, both Marshall protégés, also

certainly carried weight.

74. The President considered himself an

expert on medicine, but who raised the issue

of Kenner’s standing in the civilian medical

community is not clear. Without citing a

source, Richard Meiling names Dr. James

Paullin, president of the American Medical

Association (AMA); Dr. Frank Leahy, president of the American College of Surgeons;

Dr. Henderson, chairman of the AMA Board;

and Dr. Churchill, from Harvard. Meiling

Oral History, p. 64. Given the tantalizing picture of the internal politics of the medical

department presented by passages in Grant’s

diary, the Hawley–Kirk correspondence, and,

discretely, some of the official histories, it is

not beyond the realm of possibility that Kirk

may have been involved behind the scenes.

75. According to Richard Meiling,

Marshall issued a directive that Kirk was

never to be given an appointment unless

Marshall called for him. Marshall was distrustful of the surgeon general’s office even

before this episode and had put his “man,” an

Army surgeon, into the Inspector General’s

office to keep him informed of its activities.

Kirk had a previous association with

Secretary of War Stimson but was only sixth

in order of general efficiency ratings. The situation could not fail to have enraged the chief

of staff who was quite unhappy with medical

department internal politics. Graham A.

Cosmas and Albert E. Cowdrey, U.S. Army in

World War II. The Medical Department:

Medical Service in the European Theater of

Operations (Washington, DC: Center of

341

Notes
Military History, 1992), 504. Meiling Oral

History, p. 65. Memo for Secretary of War

from Marshall, Subj: Appointment of

Surgeon General. Feb. 21, 1943. Kirk was a

protégé of Col. Keller, who had commanded

Walter Reed Army Hospital, and was also

one of the two military doctors on the

Wadhams Committee.

76. Ltr, Stimson to the President, Apr. 10,

1943. Secretary of War TS File, box 13, RG

107, NARA II.

77. After an inspection visit to the ETO in

company with Grant and a “neutral” observer, Dr. Edward Strecker, ordered by the

President to resolve issues raised by complaints to Roosevelt about the comparative

medical care offered by the SOS and RAF to

fliers, Kirk wrote exultantly about “complete

victory” to Hawley regarding the favorable

report the three issued on their return. Kirk’s

remark tends to typify the attitude he

revealed particularly in his correspondence

with Hawley that relations between the SOS

medical department and the AAF medical

service were purely some sort of bureaucratic struggle. Grant’s diary, on the other hand,

although it reveals a man not unafraid to use

his power toward an objective, tends to reveal

a more consistent focus on improving medical care for AAF and Army troops as a

whole. The issue of comparative care seems

to have been raised by Col. Elliot Roosevelt,

who commanded a photographic reconnaissance unit in England, and not by anyone in

the AAF medical service. For a fuller discussion of this episode, see Cosmas and

Cowdrey, Medical Service in the ETO, pp.

70–71.

78. Ltr Kirk to Voorhees, Sept. 1, 1944.

Hawley–Kirk Correspondence. Kirk’s comments were uttered in the context of a lengthy

discussion about the shortages of do ctors and

nurses, and he quite rightly noted the occasional aeromedical evacuation of patients

who did not appear to need care. However,

the nurse shortage was alleviated by volunteers, and Kirk had to call on Voorhees, his

troubleshooter, to get him out of his embarrassing insistence that a nurse draft was

absolutely necessary. Mss, “My Work for the

Surgeon General,” Oct. 1945. Voorhees

papers.

Kirk’s comment about the flight nurses in

his Sept. 1 letter was cavalier: 

I am inclined to believe we should

take the thousand nurses that are now

flying around in the air and use them

on ships. No flight requires more than

a day or night and there are always

hospitals to take patients off that aren’t

transportable, and if they are properly

selected little can go wrong with them

in that length of time.

79. Cosmas and Cowdrey, Medical

Service in the ETO, pp. 184–90. The authors

portray Hawley convincingly as an extremely able man who was clearheaded to both see

and successfully address the myriad problems associated with providing the necessary

medical support of Eisenhower’s forces in

invading France and defeating the Germans

in the west. Their characterization is supported by the picture of Hawley that emerges

from his correspondence with Surgeon

General Kirk.

80. Ltr, Kirk to Hawley, Feb. 12, 1944.

Hawley–Kirk Correspondence. For a better

sense of Voorhees’ perspective, see “Informal

Account of Visit–Dictated 11 Sep 44,”

Report to Surgeon General, Subj: Visit to

China–Burma–India Theater to Survey

Medical Supply. Voorhees papers. This trip

was occasioned by complaints from the AAF

both from General Glenn as a result of his

visit and a “bitter” complaint from Maj. Gen.

Thomas J. Hanley, Jr., Commander of the Air

Service Command responsible for maintenance and supply for all U.S. air forces in the

theater, about the inadequacy of medical supply. Voorhees report, p. 7.

81. Perry Smith overstates the case somewhat but does illustrate the primary focus on

Air Force independence with which the air

staff planners approached their task. See

342

Notes
Perry McCoy Smith, The Air Force Plans for

Peace, 1943–1945 (Baltimore: The Johns

Hopkins Press, 1970), especially Chapter 2,

“The Goal of Autonomy,” pp. 15–26. As

Colonel Tyng’s letter to Hawley indicates, the

idea that the Air Force would in fact become

independent after the war was common

among members of the U.S. Army medical

department, not without some evident unhappiness at the prospect.

82. Grant, Report of Special Mission.

Nov. 23, 1944, pp. 16, 20, and 22. Grant

papers.

83. Ltr, Hawley to Kirk, Aug. 21, 1943.

Hawley–Kirk Correspondence.

84. Memo for the Chief of Staff thru the

Deputy Theater Commander, ETOUSA,

from Maj. Gen. Norman T. Kirk, David N.

W. Grant, and Dr. Edward A. Strecker, Mar.

20, 1944. Hawley–Kirk Correspondence.

Copy in Grant papers. Meiling Oral History,

p. 66.

85. Testimony, Sept. 1942, Wadhams

Committee, Vol. I, p. 380.

86. Grant diary entry for Mar. 26, 1943.

Grant papers. As noted, according to Grant,

the trip was in part undertaken to get away

from the politicking over the selection of a

Surgeon General to replace Magee.

87. Grant diary entries for Mar. 24 and 25,

1943. Grant papers. Nandi had been open

since Feb., and the base at PDG was a month

away from being declared open operationally

when Grant visited. For a brief description of

these bases see, Craven and Cate, AAF in

WWII, Vol. IV. The Pacific: Guadalcanal to

Saipan (August 1942 to July 1944) (Chicago:

University of Chicago Press, 1950), pp.

11–12.

88. Grant diary entries for Mar. 31 and

Apr. 1, 1943. Grant papers. Hospitals were

generally under command of SOS surgeons

in the rather amorphous Communications

Zone existing in the island-dotted theater.

89. Grant diary entries for Mar. 24 and 26,

1943. Grant papers. On his stop at

MacArthur’s headquarters in Brisbane, Grant

noted a great deal of overlapping, criticizing

what he termed “over organization,” and the

lack of a head with “full responsibility for the

medical service.”

90. Voorhees, “Recollections of My Work

for the Surgeon General,” Oct. 1945, p. 30.

Voorhees papers. Grant believed Voorhees to

be an impartial observer. Grant diary entry

for Jan. 20–23, 1944. Grant papers.

Chapter Four

1. For example, see John H. Stone, Crisis

Fleeting: Original Reports on Military Medi -

cine in India and Burma in the Second World

War (Washington, D.C.: Department of the

Army, Office of the Surgeon General, 1969),

especially the discussions of the role of

aeromedical evacuation in the operations of

Orde Wingate’s “Chindits” and General

Merrill’s “Mauraders” behind Japanese lines

in Burma 1943–44.

2. For earlier indications of some ground

surgeons’ attitudes toward aeromedical evacuation, see Chapter 3. Pletcher later served as

Air Force Surgeon General, 1967–70, retiring as a lieutenant general. Interview, Lt.

Gen. Kenneth E. Pletcher, USAF MC (Ret.),

Aug. 13, 14, and 15, 1990. Library, F.

Edward Hebert School of Medicine,

Bethesda, Md.

3. The study was limited in scope by the

relatively minor amount of aeromedical

evacuation conducted by the School of

Aviation Medicine, but no negative effects on

patients were observed. Lt. Cols. K. E.

Pletcher and F. L. Duff, and Sidney J. Cutler,

“An Analysis of the Effects of Aerial

Transportation on Patients,” Journal of

Aviation Medicine 20 (Aug. 1949): 252–56.

4. The creation of the defense department

and the position of the Secretary of Defense

are discussed later in this chapter.

5. The committee members selected the

questionnaire recipients based on the members’ personal knowledge of the selectees and

their experience. There are seventy-four

343

Notes
responses in the archives: thirty-one Navy,

twenty-five Army, and eighteen Air Force,

not all of which address all questions in the

questionnaire. These included, among other

things, the effects of various policies regarding the mobilization and assignment of medical personnel, military dentistry, medical

supply and logistics, duplication of medical

efforts among the services, and reasons for

the wide dissatisfaction among civilian medical professionals with their wartime service

in the armed forces’ medical departments.

The questionnaire was entitled “Deficiencies,

Operational Errors and Maldeployment of

Military Medical Resources in World War

II.” RG 330, Entry 355A, boxes 46 (Army)

and 47 (Air Force and Navy). Although not a

scientific sample, the experience of the

respondents and the nature of the committee

members who selected them make the questionnaire responses of more than passing

interest.

6. “Deficiencies, Operational Errors and

Maldeployment of Military Medical

Resources in World War II.” RG 330, Entry

355A, boxes 46 (Army) and 47 (Air Force

and Navy)

7. The unreliability of aircraft for evacuation because of tactical priorities was also

mentioned by Col. Oscar Reeder, who was

the evacuation officer for both the ETO and

North African theater of operations, U.S.

Army (NATOUSA). Ibid. Tab I, Report of

Mission to Theatres, Brig. Gen. Charles R.

Glenn, to Air Surgeon, July 22, 1944. RG 18,

Entry 50, box 2, NARA II. The AAF leaders

in the theater leadership had a very negative

view of Williams who they wanted replaced,

according to Tracey Voorhees, Kirk’s medical supply troubleshooter, who heard this

from “an authoritative source” during his

visit to the CBI in the summer of 1944.

“Miscellaneous Notes As To Medical

Department Matters in CBI Theater Outside

the Scope of the Supply Survey,” for the

Surgeon General, Aug. 17, 1944, Voorhees

papers. 

8. Board certification meant that the certified individual had met certain schooling and

experience criteria and had successfully

passed a test administered by a board of

experts from a particular specialty, such as

the American Board of Surgeons, who then

had “certified” him or her as an expert colleague in that specialty.

9. Conversation with Dr. Michael

DeBakey, Feb. 16, 1997. Dr. DeBakey

specifically noted Kirk’s medical credentials,

which made him both well known and widely respected in civilian medical circles, especially the American Medical Association.

DeBakey had wartime service in the Office

of the Surgeon General and knew Kirk well.

10. General Marshall retired in November

1945.

11. For a detailed account of the Air Force

achievement of independence within the context of the postwar unification debate, see

Herman S. Wolk, Planning and Organizing

the Postwar Air Force 1943–1947 (Wash -

ington, D.C.: Office of Air Force History,

1984). Also see Perry Smith’s previously

cited The Air Force Plans for Peace (Chapter

III).

12. Although the questionnaire responses

generally implied a belief that the chain of

evacuation would be needed to support

ground combat like that which they had witnessed in the war, several speculated about

these kinds of issues flowing from the possibility of atomic war.

13. Thomas M. Coffey, Hap. The Story of

the U.S. Air Force and the Man Who Built It,

General Henry H. “Hap” Arnold (New

York: The Viking Press, 1982), pp. 364–65.

14. W. F. Craven and J. L. Cate, The Army

Air Forces in World War II, Vol. V: The

Pacific-Matterhorn to Nagasaki (June 1944

to August 1945) (Chicago: The University of

Chicago Press, 1953), p. 39. In this original

organizational structure, each member of

Grant’s staff served a counterpart function for

20th AF, and General Grant served initially as

the 20th AF Surgeon.

344

Notes
15. Conversation with Gen. (Ret.) Jacob

Smart USAF, Feb. 11, 1997. General Smart

returned from the ETO in August to become

Secretary of the Air Staff after having spent

the bulk of the war in a German prisoner of

war camp. As secretary, he worked directly

for General Eaker.

16. Arnold also specified that the Air Staff

should become more deeply involved in

planning and policy development and that, in

keeping with the future greater importance of

technology, that regulations restricting the

responsibilities and careers of nonrated officers be changed. Wolk, Planning and Orga -

nizing the Postwar Air Force, pp. 138–39.

17. Grant diary entry for July 11, 1945.

Grant papers.

18. Grant determined to fight for the

Medical Service for which he “fought, bled,

and died.” He attributed Eaker’s hostility to a

confrontation he had in 1939 with him, then

the Executive in the Office of the Chief of the

Air Corps (OCAC). What generated the earlier confrontation is not cited, although it may

have been something during discussion of

Army Surgeon General Reynold’s attempt to

move the OCAC’s Medical Division to his

office in early 1939. Grant diary entries for

June 3, July 26, Aug. 2, 1945, Grant papers.

For discussion of the 1939 episode, see Link

and Coleman, Medical Support of the AAF in

WW II, pp. 24–26.

19. Grant diary entry for May 31, 1945.

Grant papers. Although the staff reorganization was arguably justified, it is apparent that

Eaker wanted Grant replaced for reasons that

are not altogether clear. In early July, Grant

heard from two senior flight surgeons that 1)

Eaker had actually approached the

Undersecretary of War and Surgeon General

in 1944 (that is, before Eaker’s return to

Washington) to try and have Grant relieved in

favor of Grow, and 2) Kirk had actually

approached Grow himself in mid-1944 and

offered him Grant’s job, which Grow had

refused. Eaker did state later that he favored

Grow over Grant because the former had

combat experience, but it is clear from

Grant’s diary that he and Eaker did not have

the cordial relationship that Grant had with

Arnold and other senior AAF leaders. In fact,

the picture drawn of Eaker’s attitude toward

Arnold in the diary suggests that Grant’s

close personal relationship with Arnold may

have been a factor. Eaker’s own relationship

with Arnold had deteriorated sharply: he

resented Arnold’s replacing him with General

Spaatz as director of the AAF’s strategic air

offensive against Germany in late 1943, and

he was angry about having to leave the ETO

in Mar. 1945 before the war was over. Coffey,

Hap, The Story of the U.S. Air Force and the

Man Who Built It, pp. 331–33; Parton, Air

Force Spoken Here, pp. 434, 437–38. Disil -

lusionment may have been mutual for Grant

records that Arnold told him during a discussion of rumored changes in staff organizations that he now regretted bringing Eaker in

as his deputy. Grant diary entry for July 22,

1945. Grant papers. Dr. Marquardt, the flight

surgeon who had attended Arnold in Miami

after one of his heart attacks, and Clay

Chenault, Commander of the AAF convalescent center there, both advised Grant to retire

immediately because it was only a matter of

time before Kirk and Eaker “would get him.”

Grant diary entry for June 4, 1945. Grant

papers. Interestingly, the War Department

liaison officer to the White House had sought

unsuccessfully to have General Kirk instead

of General Grant accept the aircraft for the

Army, something which the AAF refused to

countenance.

20. Grant diary entries for May 29, 30,

June 1, 1945. Grant papers. Link and

Coleman give an account somewhat at variance with Grant. According to them, Eaker

took the paper to the Deputy Chief of Staff

who disapproved the Air Surgeon’s recommendations that the AAF be given authority

to discharge its medical officers, a decision

that, according to their footnote, Eaker communicated to Grant by means of a recordand-routing (R&R) sheet. Unfortunately, the

345

Notes
authors do not give the date on the R&R, if it,

in fact, was dated. Medical Support of the

AAF in WW II, pp. 121; note 296, p. 142.

However, Grant does not record receiving

such an explanation in subsequent diary

entries, and the explanation suggests that

Arnold never saw the paper that Eaker probably discussed informally with the Deputy

Chief of Staff and Kirk. Grant records that the

acting AAF personnel director (A1) told

Grant he was willing to release AAF medical

men for three months to meet increasing congressional pressure but had been unable to do

so because of War Department policy set by

Kirk who had Secretary Stimson’s backing.

Grant diary entry July 24, 1945. Grant

papers. The issue of discharging AAF medical personnel is discussed by Link and

Coleman, Medical Support of the AAF in

WW II, pp. 119–30.

21. On Jan. 10, 1945, the Surgeon

General had submitted to the Secretary of

War (and at the secretary’s request) a memo

entitled “The Medical Mission Reappraised.”

This resulted in preparation of a draft War

Department circular [an Army-wide directive] that, if published, would have given the

Surgeon General authority to exercise “staff

supervision over the activities of the Medical

Department in all components of the Army”

(my emphasis), and specified that “all plans,

policies, and procedures having medical

aspects will be cleared with The Surgeon

General.” “Efforts to Secure War Department

Staff Status for the Surgeon General; War

Department Circular No. 120, 1945,” p. 7,

n.d. RG 18, Entry 50, box 2, NARA II. Also

see Link and Coleman, Medical Support of

the Armed Forces in WW II, pp. 114–19,

which seems to be based upon this document.

The War Department General Staff, Army

Ground Forces, AAF, and even Kirk’s commander, General Somervell, Commander of

the Army Service Forces, all opposed Kirk’s

bid. However, Kirk was an old friend of

Stimson’s from shared service in the late

1920s in the Philippines. Conversation with

Maj. Paul Daugherty, USA, MC, Feb. 16,

1997. Daugherty reviewed General Kirk’s

papers in the custody of his daughter in Jan.

1997, and noted Stimson was well known in

Kirk’s family.

22. Grant diary entries for July 2 and Aug.

4, 1945. Grant papers. Spaatz had requested

that Grow go with him to the Pacific, but, in

a conversation with Grant before leaving in

August, Grow told him that he had been

approached by Eaker on the latter’s way to

the Pentagon in March about the Air

Surgeon’s job, and that he had advised Eaker

he did not want it and that Arnold would not

let Grant go anyway. Eaker purportedly told

Grow that he thought that he could get rid of

Grant shortly after his arrival in Washington.

Grant diary entry for Sept. 12–16, 1945.

Grant papers. Arnold stayed on duty after

Marshall retired to provide some continuity

for Eisenhower, the new Chief of Staff.

23. Coleman and Link, A History of the

Origins of the U.S. Air Force Medical Service

(1907–1909), Washington, D.C.: USAF

Medical Service, n.d.). (This draft study was

never officially published.) Richard Meiling,

Oral History interview, Aug. 22, 1975.

24. .Wolk, Planning and Organizing the

Postwar Air Force, p. 34.

25. Ibid.

26. Wolk, Planning and Organizing the

Postwar Air Force, p. 35.

27. Grant diary entries for Aug. 7, 15, and

20, 1945. Grant papers.

28. AAF Ltr 25-74, Aug. 20, 1945, Subj:

Relation of the AAF Medical Service to

Command, to Commanding Generals, Major

AAF Commands; Commanding Generals

and Commanding Officers, Independent

AAF Activities, Subordinate AAF

Commands and AAF Divisions, Wings and

Districts; Commanding Officers, AAF Base

Units (not included above), from H. H.

Arnold, Commanding General. Copy in

Grant papers.

29. Wolk, Planning and Organizing the

Postwar Air Force, p. 126. Arnold requested

346

Notes
retirement in a memo to Marshall on Nov. 8,

1945, and by the end of the year was on terminal leave. He did not formally retire until

Feb. 9, 1946. Arnold’s memo is printed in his

autobiography, Global Mission (New York:

Harper Brothers, 1949), pp. 608–609. Coffey,

Hap, p. 376. It was Eisenhower, of course,

whose preference for Spaatz over Eaker

when he took over the ETO had resulted in

Arnold’s reassigning the latter to the

Mediterranean Allied Air Forces, and Arnold

told Eaker of Eisenhower’s role. Coffey,

Hap, pp. 331–33.

30. Marshall directed Lt. Gen. Alexander

Patch to chair the study in late August 1945,

but Patch died shortly after Gen. Eisenhower

became Army Chief of Staff. Marshall picked

Simpson to complete it, and Simpson delivered his report in late December, which,

among other things, called for an

autonomous AAF as a step toward independence. War Department Circular 138 embodied most of its recommendations and was

published on May 14, 1946, to be effective

June 11, 1946. Notably, the circular abolished

the Army Service Forces and restored the

Surgeon General’s direct access to the Chief

of Staff.

31. Wolk, Planning and Organizing the

Postwar Air Force, p. 111. The board had

originally recommended that the Surgeon

General exercise technical and administrative

supervision and inspection of subordinate

units of the medical service not commanded

by him and not under his immediate control,

which would basically have restored the pre1941 situation for flight surgeons on AAF

bases.

32. Wolk, Planning and Organizing the

Postwar Air Force, p. 111. The other technical services, such as the engineers, also had

their organizational autonomy restored with

Circular 138’s abolition of the ASF.

33. Link and Coleman, A History of the

Origins of the U.S. Air Force Medical Service

(1907–1909), Washington, D.C.: USAF

Medical Service, n.d.), p. 119. Grow and

Grant had discussed the future of the AAF

Medical Service at some length shortly

before the war ended and had agreed that its

wartime status should be retained. Grow had

also said that he would talk to Eaker about the

matter. Grant diary entry for Aug. 3, 1945.

Grant papers.

34. Link and Coleman, Origins of the AF

Medical Service, p. 116.

35. The Simpson Board’s recommendations pertaining to the Medical Department

are covered in Link and Coleman, Origins of

the USAF Medical Service, pp. 133–36. Kirk

left the Surgeon General’s post on May 31,

1947, and retired from the Army on July 31,

1947.

36. Quoted in Link and Coleman, Origins

of the AF Medical Service, pp. 143–44. Denit

became acting Surgeon General following

Kirk’s retirement in July 1946. He had served

with considerable distinction in both the ETO

and the Pacific theater during World War II.

37. The ZI-based commands established

included the Strategic Air Command (SAC),

Tactical Air Command (TAC), Air Defense

Command (ADC), Air Training Command,

Air University, and Air Materiel Command,

with which the USAF was to “fight” most of

the Cold War.

38. Wolk, Planning and Organizing the

Postwar Air Force, p. 137.

39. The statistics for the period show a

dramatic decline from the last years of the

war but are skewed somewhat because of the

changes in evacuation means used in peacetime. During the war, the majority of patients

evacuated to the U.S. were carried in vesselshospital ships, converted troop transports,

even converted ocean liners like the Queen

Mary. Evacuation by aircraft in the postwar

world was predominantly by aircraft.

Statistical History of the Air Transport

Command, 29 May 1941–31 May 1948

(Washington, D.C.: Headquarters ATC, n.d.),

History Office, Air Mobility Command

(AMC/HO), Scott AFB, Ill.

40. Futrell, Development of Aeromedical

347

Notes
Evacuation in the AF. Approximately twenty-eight thousand patients were evacuated by

all means from overseas to hospitals in the

United States during calendar year (CY)

1946, but only about half that number in the

following calendar year. National Military

Establishment. Annual Report of the

Secretary of the Army. 1948 (Washington,

U.S. Government Printing Office, 1949), p.

270. The Secretary’s report does not indicate

what part of these numbers were carried by

air, but statistics suggest that the overwhelming majority of the approximately 14,200

evacuees in CY 1947 were moved by

aeromedical evacuation.

41. Futrell, Development of Aeromedical

Evacuation in the AF. The process of assigning personnel from theater MAES to ATC

had begun during the war as the intertheater

use of aeromedical evacuation expanded with

larger numbers of casualties, particularly

from the ETO after the invasion, and the

availability of larger numbers of C–54s. In

late Nov. 1944, for example, the War

Department increased the authorized strength

of the 830th to 46 officers, 270 nurses, and

354 enlisted men (EM). Ltr, Adjutant General

(AG) to Commanding General, ATC, Nov.

27, 1944, Subj: Augmentation of the 830th

Medical Air Evacuation Squadron.

AMC/HO. Four months later, several more

MAES were disbanded in the ETO, and the

830th’s authorization was again increased,

this time to 58 officers, 345 nurses, and 450

EM. Ltr, AG to Commanding Generals, U.S.

Forces in the ETO ATC, Mar. 26, 1945, Subj:

Reassignment, Disbandment and Augmen -

tation of Certain Medical Air Evacuation

Squadrons. AMC/HO. Ironically, one of the

MAES not decommissioned, the 806th, was

stationed at Villacoublay near Paris, which

had been the base for Dr. Chaissing’s air

ambulances in 1917. See Chapter 1.

42. At the end of Dec. 1947, of 3,000 regulars authorized for the Army Medical Corps,

there were 1,206 in uniform; of 2,258 authorized for the Army Nurse Corps, there were

1,148 in uniform; and, of 1,022 authorized

for the Medical Service Corps, 740 were in

uniform. The highly educated and skilled

doctors who patriotically entered the Army

during the war were in great demand in civilian life, but their principal reasons for leaving

centered on their dislike of the regimentation

and the absence of opportunities to practice

their professional specialties. Albert E.

Cowdrey, United States Army in the Korean

War: The Medics’ War (Washington, D.C.;

United States Army Center of Military

History, 1987), p. 11. Grow also sponsored

an airborne field hospital project being conducted at the School of Aviation Medicine

(SAM). Ltr, Col. Harry Armstrong, Com -

man dant SAM, to the Air Surgeon, Sept. 4,

1947.

43. The text of the Norstad–Sherman

agreement is printed in Alice C. Cole, Alfred

Goldberg, et al., eds., The Department of

Defense: Documents on Establishment and

Organization 1944–1978 (Washington, D.C.:

Office of The Secretary of Defense Historical

Office, 1978), pp. 31–33.

44. Ibid.

45. The Hall Board is discussed in Wolk,

Planning and Organizing the Postwar Air

Force, pp. 162–63, and Link and Coleman,

Origins of the USAF Medical Service, pp.

147–48.

46. Wolk, Planning and Organizing the

Postwar Air Force, p. 195.

47. Ibid.

48. Ibid. Eisenhower quote in Link and

Coleman, Origins of the USAF Medical

Service, p. 164.

49. Link and Coleman, Origins of the

USAF Medical Service, 163.

50. The Hoover Commission had committees and task forces assessing the Federal

Medical Services and whether they should be

organized under a single head. Schemes to

amalgamate all hospitalization for the

Federal Medical Services–including Army,

Navy, and Air Force, the Public Health

Service, and Veterans Administration, each of

348

Notes
which would have its own Surgeon General

responsible to a new Secretary of

Health–were being proposed within the AAF

as early as May 1945, and discussed with

several senators. Grant diary entry for May

28, 1945. Grant papers. Russell Lee of the Air

Surgeon’s staff proposed such an organization and discussed it with Grant who thought

it “ideal, but it will never work.” The issue of

national health insurance was prominent in

the presidential election year of 1948,

President Truman having called Congress

back into session after its normal adjournment because it had failed to enact such

insurance according to his acceptance speech

for the Democratic nomination for president.

Washington Report on the Medical Sciences

(July 19, 1948), p.1.

51. According to Richard Meiling, Kirk

had convinced Eisenhower of the need for a

unified medical service on a visit to England

before he returned to be Army Chief of Staff.

Hawley, who was to later formally favor such

an arrangement, may also have been a factor

in helping convince Eisenhower of such a

need because of Hawley’s success in directing the Army medical service in the ETO during the war. Meiling Oral History.

52. Quoted in Link and Coleman, Origins

of the USAF Medical Service, p. 174. Later in

his testimony, he was more specific about the

need for “more planning, more brains put

on...the long term program of providing for

the medical services in case, ever, of a war in

which we may visualize the use of an atomic

bomb” (p. 176). The topic was given considerable attention; for example, The

Washington Daily News published a long

article “Disaster Plan Being Prepared for

Atom War,” on Sept. 3, 1948. RG 264, Entry

18, box 7, “Newspapers.”

53. The quote is from Kirk’s statement to

the committee. Link and Coleman, Origins of

the USAF Medical Service, p.194.

54. Ibid.

55. Link and Coleman, Origins of the

USAF Medical Service, p. 195.

56. Link and Coleman, Origins of the

USAF Medical Service, p. 195.

57. “Transportation of the Sick and

Wounded” (Washington, D.C.: United States

Government Printing Office, Feb. 1945).

58. Pletcher Oral History, Aug. 13, 14,

and 15, 1990. USUHS Library, F. Edward

Hebert School of Medicine. There is no evidence that the Eaker situation gave Grant any

pause with regard to his commitment to the

Air Force.

59. The drive to professionalize the medical department and its reasons are described

in Cowdrey, United States Army in the

Korean War, pp. 14–16. Dissatisfaction with

the Army by doctors who had served for the

duration also had roots in the regimentation

and privations of Army life, a dissatisfaction

that extended to the AAF. One doctor who

had served in the southwest Pacific responded

to a letter of thanks for his service by David

Grant: “Do not kid us any further. Your letter

and our experience findings do not add properly. So leave well enough alone. We are U.S.

taxpayers now.” Note, Dr. Warren Fake to the

Air Surgeon, n.d., typed on Grant’s Ltr to

Fake, Oct. 6, 1945. Original in Grant papers.

60. Grow was pressing development,

among other things, of an airborne field hospital. Ltr, Col. Harry Armstrong, Comman -

der, SAM, to Grow, Sept. 1947.

61. The text is printed in Alice Cole, et al.,

DoD Documents on Establishment and

Organization, pp. 35–50.

62. Ibid.

63. Link and Coleman, Origins of the

USAF Medical Service, p. 236.

64. Link and Coleman, Origins of the

USAF Medical Service, p. 238.

65. WRMS, 67, Sept. 13, 1948.

66. Other committees included the

National Security Resources Board, the

Committee on Medical Science of the

Research and Development Board, the

American Medical Association’s Council on

National Emergency Service, and the Air

Force Association, which passed a resolution

349

Notes
in Nov. 1947 calling for a USAF medical service as an organizational element of the

USAF. WRMS, 67, Sept. 13, 1948. Link and

Coleman, Origins of the USAF Medical

Service, pp. 238–40.

67. For example, see Appendix A,

“Recommendations of the Committee on

Federal Medical Services,” Nov. 1, 1948. RG

264, Entry, 36, box 12. The Eberstadt

Committee report was published on Nov. 15,

1948; the Voorhees Committee on Federal

Medical Services on Nov. 1, 1948, and the

Hawley Committee’s report not until July 5,

1949.

68. Link and Coleman, Origins of the

USAF Medical Service, p. 327.

69. Based heavily on interviews with the

key participants soon after the events, Link

and Coleman’s Origins of the USAF Medical

Service is the best study to date, although the

first chapter (“Between the Wars”) of

Cowdrey’s The Medics’ War provides an

excellent brief description of the background

events from an Army point of view, especially pp. 22–28 on unification. The retirement of

both Eisenhower and Spaatz in 1948 helped

clear the way for the agreement to separate

the medical services.

70. Arnold, Global Mission.

71. Betty Kennedy, Air Mobility En Route

Structure: The Historical Perspective,

1941–1991 (Scott AFB, Ill.: Headquarters

Air Mobility Command, Sept. 1993), p. 9.

72. This seems to have been instigated by

Richard Meiling who by this time was

Director of Medical Services and Assistant to

Secretary of Defense Louis Johnson, who

had succeeded Forrestal. Meiling makes a

convincing case in his oral history memoir,

but his memory of the timing of this episode

is not consistent with the actual date of the

directive. See Meiling Oral History, p. 167.

73. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 161.

74. For the development of Army air

observation posts, see Edward Raines, “The

Origins of Modern U.S. Army Aviation in

World War II,” unpublished mss., U.S. Army

Center of Military History, Jan. 25, 1995.

This definitive work will be published by the

Center in the near future. I am indebted to Dr.

Raines for his kind permission to review the

manuscript prior to publication.

75. Raines, “The Origins of Modern U.S.

Army Aviation in World War II, pp. 46–47.

Conversation with Dr. Raines, Jan. 17, 1997.

76. Grant diary entry for Aug. 8, 1945.

Grant papers. Eaker had announced the policy of expanding the number of aircraft organic to Army ground unit a few days before.

77. David M. Lam, “From Balloon to

Black Hawk. The Army Forward Aero medical

Evacuation Story. Part I: The Origins,” U.S.

Army Aviation Digest (June 1981), pp. 46–47.

78. Lam, “From Balloon to Black Hawk,”

p. 48. Summary of aeromedical evacuation

experience of Maj. Gen. Spurgeon Neel. Neel

chaired the board that conducted the tests.

Center of Military History Files.

Chapter Five

1. For example, see Capt. Francis P. Thorp,

ANC, “Problems in Aerospace Nursing,”

Journal of Aviation Medicine (Apr. 1949):

136–39, based on a paper she presented to the

19th Annual Meeting of the Aeromedical

Association in June 1948. The “problems” she

discusses are, in order, inflight feeding, sanitary facilities, nursing care, and communications. These clearly are problems for effective

patient movement by air, but they relate much

more to the residual MATS aeromedical evacuation system of the immediate postwar period than evacuating casualties from the combat

zone. The quotation is from a draft Chapter II,

“The Korean War,” in an anonymous draft

mss. on the Army and aeromedical evacuation

in the Vietnam War, n.d., RG 319, CMH

Refiles, “Dust-off,” box 3, NARA II.

2. Robert Frank Futrell, The United States

Air Force in Korea 1950–1953 (New York:

Duell, Sloan and Pierce, 1961), note, pp. 544-

45.

350

Notes
3. Robert Frank Futrell, Development of

Aeromedical Evacuation in the USAF, pp.

161–62; “Main Differences Table,” T.O. 1C54M-1, “USAF Series C–54M Aircraft,

Flight Handbook,” Apr. 15, 1957; and

“Characteristics Summary, C–54M,” July,

1961. I am indebted to Mr. David Menard,

Air Force Museum Office of Research,

Wright-Patterson AFB, Ohio, for this information. Robert Frank Futrell in his pioneering study of aeromedical evacuation in the

USAF asserts flatly that no C–97s were

reconfigured as medical aircraft like the

MC–54Ms in time for use during the Korean

War. However, archival sources indicate the

first of ten MC–97s were delivered beginning

in Feb. 1951. See Futrell, p. 190. (ASI never

published Futrell’s study in final edited form.

Page references are to an unedited single

spaced version retyped and published by the

375th Aeromedical Airlift Wing (MAC),

Scott AFB, Ill., Jan. 1977).

4. “Airborne Hospital. Lightweight, compact field unit is designed for air transport.”

Life Magazine (Sept. 13, 1948): 161–62.

Malcolm Grow was particularly interested in

the airborne hospital. See Ltr, Col. Harry G.

Armstrong, Commandant of School of

Aviation Medicine, to Grow, the Air Surgeon,

Sept. 4, 1947, and Grow’s annotations. RG

341, Entry 44, box 93, NARA II. Grow

noted, apropos the suggestion that SAM prepare to demonstrate the complete airborne

hospital to the Army Surgeon General, Maj.

Gen. Bliss, that Bliss “should be willing to

share in this project but probably won’t”

[emphasis in the original].

5. “Air Evacuation Vehicles in the 20th

Century,” Appendix I to Draft Chapter II,

“The Korean War.” RG 319, 19, CMH

Refiles, “Helicopters,” box 4. NARA II.

6. The Air Force offered promotions and

other incentives to those who chose to serve

in the new organization, a fact that left a bitter taste in the mouth of the Army Surgeon

General and his senior staff. Interview, Col.

(Ret.) Robert Joy, USA MC, Apr. 5, 1997. Dr.

Joy is the emeritus director of the Medical

History Program at USUHS.

7. Maj. Gen. George E. Armstrong, who

succeeded Bliss as the Surgeon General of

the Army, noted while serving as Bliss’s

deputy that, in spite of a variety of measures

designed to help, the medical department was

still five hundred doctors short of its full

requirement for providing medical care to the

JCS-specified 667,000-man army. The

Military Surgeon 106 (Mar. 1950): 31. The

drive for greater professionalization was also

present in military nursing. For example, see

Agnes Gelinas, “Nursing Education Today–

Civilian and Military. The Educational Pro -

gram Available for Student Nurses in Schools

of Nursing Today,” The Military Surgeon 106

(Mar. 1950): 203–07; and Marguerite C.

Holmes, “The Educational Programs

Available for Graduate Nurses in Universities

and Colleges,” The Military Surgeon 106

(Mar. 1950): 207–09. Both articles and several others related to professional educational

opportunities for military nurses originated as

papers presented to the Association of

Military Surgeons at their 1949 Annual

Meeting. The quotation is from Brig. Gen. J.

I. Martin, “Medical Field Service,” The

Military Surgeon 104 (Apr. 1949): 251. Like

those just cited, this article was first presented as a paper to an annual meeting of the

Association of Military Surgeons.

8. For a sense of the intensity of the services’ struggle to find resources, see Jeffrey

Barlow, The Revolt of the Admirals (Wash -

ing ton: Naval Historical Center, 1995). In

such circumstances, the medical services

necessarily had lower priority.

9. Richard Tierney, The Army Aviation

Story (Northport, Ala.: Colonial Press, 1963),

206. Also see B. Franklin Cooling, “A His -

tory of Army Aviation,” Aerospace His -

torian:104.

10. Hastings, The Korean War, 52–53.

11. For a brief discussion of the background to the President’s action, see

Hastings, The Korean War, pp. 54–75.

351

Notes
12. See Bevin Alexander, Korea: The

First War We Lost (New York: Hippocrene

Books, 1986), pp. 46–62, for a discussion of

the state of training of the occupation forces.

13. Alexander, Korea, p. 58. Alexander

describes the fate of “Task Force Smith”

vividly on pp. 53–62. Also see Fehrenbach,

This Kind of War, pp. 65–71.

14. Futrell, USAF in Korea, pp. 12–13.

15. Futrell, Development of Aeromedical

Evacuation in the USAF, pp. 165–66. The

heavier C–46s were soon ruled out of the

Korean airlift because of the damage they

began to cause to critical airfields like that at

Pusan (K9). They later played a major role in

aeromedical evacuation after the recapture of

Kimpo and Suwon and the work of engineers

who improved many fields.

16. Additionally, the road from Ashiya to

Fukuoka, although paved, was very poor in

places, making road transportation of casualties somewhat risky. The author was stationed at Ashiya from Oct. 1953 until Aug.

1955.

17. Ibid., p. 167. Capt. Annis G.

Thompson, The Greatest Airlift: The Story of

Combat Cargo (Tokyo: Dai-Nippon Printing

Company, 1954), p. 6. Thompson witnessed

a number of events discussed in his book as a

pilot in a troop carrier wing that arrived in

Japan in Nov. 1950. He subsequently became

the public information officer and historian of

the 315th Air Division (Combat Cargo),

which operated the aeromedical evacuation

system. Albert E. Cowdrey, who wrote the

official account of the U.S. Army medical

department in the Korean War, apparently

was unaware of the C–54 “backhauls” from

Kyushu having been integrated into the intraJapan aeromedical evacuation system from

the earliest days of the war. He writes of general hospital patients having to endure fifteen-hour train rides to Osaka or having to

travel twenty-seven hours to Tokyo from the

station hospital at Fukuoka and implies that

this continued until Jan. 1951. The Medics’

War(Washington, D.C.: U.S. Army Center of

Military History, 1987), pp. 266–67.

18. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 167. The 8th

Army Surgeon set the evacuation policy for

Korea at thirty days.

19. Ibid.

20. Draft Vietnam aeromedical evacuation mss., Chapter I, p. 19. Commenting on a

proposal for the “snatching” of capsules containing casualties as a means of frontline

evacuation, Col. George Baier, Chief of the

Operations Division of the Air Surgeon’s

Office, rejected it with the recommendation

that helicopter evacuation was much better.

Ltr to Col. Chenault, Nov. 3, 1944. RG 341,

Entry 44, box 93, NARA II. Helicopters were

used both in China and the Philippines. Col.

M. S. White, “The Air Evacuation of Ground

Force Troops,” The Military Surgeon 101

(Aug. 1947): 104.

21. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 165. Quote is

from David M. Lam, “From Balloon to

Kittyhawk. Part II: World War II,” U.S. Army

Aviation Digest, (July 1981): 48.

22. Oral History, General Spurgeon Neel,

Mar. 3, 1977, p. 1; Neel CV, n.d., files

USUHS Medical History Office, p. 1. Neel in

his interview said the tests were conducted

with an H–5. In his CV, he indicates it had

internal storage for two litters (which H–5s

did not). David Lam identifies the test helicopter as the Sikorsky YH–18, and is almost

certainly correct. Lam, “From Balloon to

Kittyhawk. The Army Forward Aeromedical

Evacuation Story. Part II: World War II,” p.

48.

23. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 169.

24. Cowdrey, The Medics’ War, pp.

94–95.

25. Futrell, Development of Aeromedical

Evacuation in the USAF, pp. 173–74.

Stratemeyer had commanded the Eastern Air

Command during World War II and was certainly aware of the wartime aeromedical evacuations carried out in the CBI during 1944.

352

Notes
26. Futrell, Development of Aeromedical

Evacuation in the USAF, pp. 173–74.

27. Spurgeon H. Neel, “Helicopter

Evacuation in Korea,” U.S. Armed Forces

Medical Journal VI (May 1955): 691–92.

28. Futrell, The United States Air Force in

Korea, pp. 148–49.

29. Ibid.

30. Futrell, The United States Air Force in

Korea, pp. 546–47. Cowdrey, The Medics’

War, p. 264.

31. Futrell, Development of Aeromedical

Evacuation in the USAF, pp. 170, 184.

“Medical Air Evacuation,” FEAF Report on

the Korean War, Vol. II (Mar. 26, 1954), 24.

(File: 168.7082-572, box 65, HRA.)

32. Ibid.

33. Mossman, Ebb and Flow, p. 237.

Later, in January, Ridgway was to write of his

situation, “what I had [in combat units] was

all there was.”

34. Lt. Col. Lucille C. Slattery, “Air Force

Nurses Progress Toward the Space Age,” pp.

12–13; paper presented to the 66th Annual

Convention of the Association of Military

Sur geons, Nov. 9, 1959. Col. Slattery recoun -

ted her experiences as part of this presentation. The 8055 MASH was the most forward

Army Mobile Army Surgical Hospital at the

time.

35. Thompson, The Greatest Airlift, p. 39.

Thompson’s account of airlift and aeromedical evacuation’s role in the retreat from the

Changjin Reservoir is particularly good.

Although his sources are not indicated in his

text, given his own experience and access to

information, including other participants, as

well as the near contemporaneous nature of

his writing, the book must be considered

authoritative on what happened if not necessarily why. The author can validate much of

the context of the events from his own experience in the 315th Air Division flying

C–119s at Ashiya.

36. The figure for those evacuated comes

from Futrell, Development of Aeromedical

Evacuation in the Air Force, p. 27, who used

the FEAF Combat Cargo Command History

for the period Sept. 10, 1950 to Jan. 24, 1951;

see note 27, p. 282. Cowdrey says nothing

about aeromedical evacuation from Hagaruri or Koto-ri by C–47s, although he mentions

Marine helicopters lifting casualties from isolated units and transferring them to airstrips

where X Corps liaison planes flew them to

medical facilities, presumably at Hungham.

The Medics’ War, pp. 122–23, 125–27. By

contrast, Alexander calls the Hagaru-ri

airstrip “one of the great legends in man’s

conquest of the air, a testament to man’s

determination.” Alexander, Korea, p. 356.

37. Thompson, The Greatest Airlift, p.56.

Futrell, Development of Aeromedical Evac -

uation in the USAF, p. 170.

38. Futrell, The USAF in Korea, pp. 319,

549; Development of Aeromedical Evacua -

tion in the USAF, p. 174. Earl H. Tilford, Jr.,

The USAF in Southeast Asia: Search and

Rescue in Southeast Asia (Washington, D.C.:

Center for Air Force History, 1992), pp.

12–13. Neel, “Helicopter Evacuation in

Korea,” p. 692.

39. For example, the 395th Station

Hospital at Nagoya expanded from 100 beds

in June 1950 to 500 beds in Oct. and 1,200 in

Jan. 1951. It received patients aeromedically

evacuated from Korea and Itazuke through

Komaki air base and others moved by rail

from southern Japan. “Historical Data for the

Period 1 October 1950 to 31 January 1951,”

Feb. 19, 1951. (File: KHOS-STA 395-H1,

Oct 50–Jan 51, box 40, HRA.)

40. Cowdrey, The Medics’ War, p. 269;

Futrell, Development of Aeromedical Evac -

uation in the USAF, p. 173.

41. In June 1951 as C–54s were once

again able to operate into airfields in central

Korea as UN forces were driving north, the

315th Surgeon, Col. Allen Smith, strongly

urged that patients be cleared directly from

Seoul and Hoengsong to save the additional

hardships of multiple movements and to

reduce airlift requirements. Once again,

Eighth Army refused and would clear

353

Notes
patients to Japan only from the evacuation

hospitals at Taegu and Pusan. Ibid., p. 173;

Cowdrey, The Medics’ War, p. 269. The

Army evacuation chain is depicted schematically in Cowdrey, The Medics’ War, p. 152.

42. During July and August, 1,849 evacuees from Pusan to Kokura, the Japanese port

through which they were moved by train to

Army hospitals in Japan, were carried by the

USS Maine which had only one air-conditioned ward, with temperatures elsewhere

below decks rising above 100 deg. Cowdrey,

The Medics’ War, p. 263.

43. Thompson, The Greatest Airlift, p.56.

On Dec. 5, 1950, 3,925 patients were aero -

medically evacuated from Korea for safety’s

sake.

44. Neel, Oral History, pp. 13–14.

General Armstrong, the Army Surgeon

General, argued somewhat similarly defending the adequacy of general Army evacuation

methods against the charge that the Army

chain of evacuation was inferior to that of the

U.S. Marines in Korea. Cowdrey, The

Medics’s War, pp. 194–95.

45. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 175.

46. Ltr, Col. B. Warden, Adjutant

General, FEC, to CG, 8th Army, et al., Subj:

Air Transportation of Patients within the Far

East Command and Korea, cited in Futrell,

Development of Aeromedical Evacuation in

the USAF, p. 181.

47. Office of the Surgeon General,

Theater Aeromedical Evacuation System,

n.d. (internal evidence indicates it was published after Apr. 1951), foreword by the Air

Force Surgeon General, General Armstrong,

p. 17. Armstrong identifies this document,

which was classified “Restricted,” as a “manual” and the Introduction notes that it had

been compiled “to serve as a guide in training

personnel for the establishment, operation,

and continuing development of the

Aeromedical Evacuation System.” Although

there is no AF manual number, the document

was clearly issued and was not merely a draft.

(File: 1268.2082-568, 51/00/00. HRA.)

48. Office of the Surgeon General,

Theater Aeromedical Evacuation System, p.

21. For example, the C–123 could carry fifty

litter or sixty ambulatory patients. Theater

Aeromedical Evacuation System, p. 61.

49. General Eisenhower’s strong views

on air support of ground forces had been a

factor in the original creation of TAC, but

there was also a defensive element. The AAF

leadership in 1946, looking toward independence, was well aware that the Army sought

control of tactical aviation, and, if a separate

organization for tactical support of the Army

ground forces had not been created, the Army

would have sought to achieve it. Wolk,

Planning and Organizing the Postwar Air

Force, pp. 131–32.

50. After observing the utility of Marine

helicopters to Marine operations in general,

the 8th Army Commander, Gen. Matthew

Ridgway, became enthusiastic about their

potential value to the Army. In Nov. 1951, he

requested that the Department of the Army

send him four helicopter transport battalions,

each to be equipped with 280 helicopters. He

asserted that the Korean War had shown the

Army vitally needed helicopters and recommended the future typical field army have ten

helicopter transportation battalions. The

Army followed his recommendation regarding the future field army but scaled it down to

four helicopter transport battalions, each with

three companies. Futrell, The USAF in

Korea, pp. 333–334.

51. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 184. FEAF interpreted the dispute, which involved “a maze

of statements and counter-statements,” as not

over professional jurisdiction “but rather over

administrative control of patient movement

and evacuation.” FEAF Report on the

Korean War, p. 24.

52. Col. Adriel N. Williams,

“Aeromedical Evacuation in a Theater of

Operations,” Air War College thesis, Mar.

1953, Air University Library, Maxwell AFB,

354

Notes
Ala. Williams had served on a special TAC

study group, Project Vicksburg Blue, evaluating aeromedical evacuation. Somewhat ironically, Williams’s assignment after the Air

War College was as commander of the 374th

Troop Carrier Wing at Tachikawa.

53. Quotes from Memo of Understanding

between the Secretary of the Army and the

Secretary of the Air Force, Oct. 2, 1951, in

Richard I. Wolf, ed., The United States Air

Force: Basic Documents on Roles and

Missions (Washington, D.C.: Office of Air

Force History, 1987), p. 22.

54. Williams, “Aeromedical Evacuation,”

pp. 18–19. Jean R. Monk, A History of

Large-Scale Army Maneuvers in the United

States, 1935–1964 (Fort Monroe, Va.: Histo -

rical Branch, Continental Army Command,

Dec. 1969), p. 179.

55. Quotations are the text printed in

Wolf, Basic Documents, pp. 243–45.

56. In his thesis, Williams proposes an Air

Force-operated forward evacuation system

such as that proposed by the Project

Vicksburg Blue study group chaired by the

TAC Surgeon, Col. M. S. White, and of

which Williams had been a member. Its

report was filed in July 1952. Williams,

“Aeromedical Evacuation;” Introduction and

Phase I: Aeromedical Evacuation: Project

VICKSBURG BLUE (Langley AFB,

Virginia: Headquarters TAC, File: 168.7082-

571, HRA.)

57. “Concept of Aeromedical Evacuation

in Overseas Combat Areas,” foreword by

Maj. Gen. Chester McCarty, CG, 18th Air

Force. (File: K237.163.3, 52/03/20–55/04/00

HRA.)

58. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 187.

59. Ibid.

60. Appendix I, to draft study “ Aero -

medical Evacuation in Vietnam,” p. 176. RG

319, CMH Refiles, Dust Off, box 4, NARA II.

61. Memo for the Surgeon General, Subj:

The Civil Reserve Air Fleet, Apr. 2, 1952,

from Maj. Gen. Robert E. Lee, Director of

Plans with cover routing memo, Col.

Maurice Johnson, Deputy Surgeon General,

for Col. Allen Smith, n.d. (File: K237.163-3,

HRA.) For a brief discussion of the CRAF

origins, see Anything, Anywhere, Anytime,

pp. 81–86.

62. Lt. Gen. William H. Tunner, Over the

Hump (Wash., D.C.: Office of Air Force

History, 1985), p. 287. Also see Ltr, Tunner to

Thomas D. White, Air Force Chief of Staff,

July 17, 1959. “Commands, MATS,”

Thomas D. White papers, LC/MD. Any

Thing, Any Where, Any Time also discusses

the role of Congress in acting as critic on

behalf of the commercial carriers (pp.

94–98).

Chapter Six

1. See Chapter 5 for the provisions of the

manual. The manual was published as AFM

160-27, NAVMED P-5047, and FM 31-8,

dated Jan. 9, 1956.

2. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 202. The Air

National Guard Medical Service. A

Perspective from 1947 to the Present: The

Annual Reports, Chief National Guard

Bureau (Andrews AFB, D.C.: Air National

Guard Readiness Center, July 4, 1992)

(Report, 1956), pp. 41–42; (Report 1958), p.

56.

3. Futrell, Development of Aeromedical

Evacuation in the USAF, pp. 201–202.

4. “Air Evac Flights Slated for Demise,”

Army–Navy–Air Force Journal (Mar. 5,

1960): pp. 1, 28; “Medical Airlift System Will

Phase Out by `63,” Air Force Times (Mar. 19,

1960), pp. 28. The Journal editorialized

sharply against the idea in the same issue in

which it published the story on the proposed

cuts. In a conversation, Apr. 10, 1997, Dr.

Futrell indicated his belief that his unpublished study on aeromedical evacuation may

have helped influence General White’s decision to retain the mission for the active force.

Clearly, there would have been pressure from

355

Notes
elsewhere too because this was an assigned

Air Force mission. Maj. Gen. Twitchell, the

former Surgeon of the United States Air

Forces in Europe (USAFE), in a contemporary interview (1961), speaking about the

aeromedical evacuation system, noted that

decisions that had “practically eliminated the

system within [the] Continental United

States” had been made “without any reference

to the Surgeon General’s office.” Oral

History, General Harold H. Twitchell, USAF

MC, May 8, 1961. (File: K230.052-568,

HRA.) The plan was abandoned several

months later. “Air Evac Demise Plans

Rescinded,” Army–Navy–Air Force Journal

(July 2, 1960): 1.

5. (Donaldson AFB, S.C.: Headquarters

18th Air Force, n.d.), pp. 16–17. Foreward

signed by the commander, Maj. Gen. Chester

E. McCarty, USAF. (File: K237,163.3,

52/03/20–55/04/00, HRA.) Quotation is from

“Theater Aeromedical Evacuation System,”

p. 22.

6. “Concept of Aeromedical Evacuation

in Overseas Combat Areas,” 15.

7. Lam, “From Balloon to Kittyhawk:

Part III: Korea,” p. 46.

8. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 221. The Army

Air Corps had, of course, procured two CoxKlemin aircraft, which were especially

designed for air ambulance work in the latter

part of the 1920s. (See Chapter 2.) C–131E

models obtained by MATS later had not been

designed for aeromedical evacuation and

after modification could carry only twelve litter and eighteen ambulatory patients. Futrell,

Development of Aeromedical Evacuation in

the USAF, p. 221.

9. Futrell, Development of Aeromedical

Evacuation in the USAF, p. 221.

10. Ibid.

11. Futrell, Development of Aeromedical

Evacuation in the USAF, pp. 220, 223–25.

12. Input for the period Jan. 1, 1965–Mar.

31, 1968, to Corona Harvest, Vol. I, 1st

Casualty Staging Flight, USAF Hospital,

Scott AFB, May, 1969, p. 5, HRA. Although

the number of patients processed during 1965

fell to 3,365, none of whom were battle casualties, difficulties still existed in handling

patients who remained over night (RON).

Corona Harvest is the code name for the massive USAF project to document its role in the

Vietnam War. Documents from this collection located at the USAF Historical Research

Agency (HRA), will hereafter be identified

as Corona Harvest reports in the interest of

brevity. For a discussion of the project, see

Robert F. Futrell, Ideas, Concepts, Doctrine:

Basic Thinking in the United States Air

Force, 1961–1984, Vol. II (Maxwell AFB,

Ala.: Air University Press, 1989), pp.

316–23.

13. Corona Harvest Report, 2nd CSF, Jan.

1, 1965–Mar. 31, 1968, Vol. I, July 1, 1969,

p. 1. Corona Harvest, 1st CSF, 1965–1968, p.

7. Futrell, Development of Aeromedical

Evacuation in the USAF, pp. 224–25. These

CSF tasks were those proposed by 18th Air

Force and approved by TAC in 1955.

14. Charles E. Miller, Airlift Doctrine

(Maxwell AFB, Ala.: Air University Press,

1968), p. 240. Quotation is from the DOD

directive printed in Wolf, USAF Basic

Documents on Roles and Missions, p. 309.

15. Miller, Airlift Doctrine, p. 240.

16. Various directives published in the

late 1950s and in the 1960s predating the

introduction of U.S. combat troops into

Vietnam dealt with aeromedical evacuation

at general and theater levels. These included

Air Force Regulation 164-1, “World-wide

Aeromedical Evacuation,” May 15, 1964;

MAC Reg. 160-2, “Aeromedical Evacua -

tion,” Apr. 28, 1961; and PACAF Manual

55–13, “Pacific Air Forces in Joint Opera -

tions,” Chapter 7, Apr. 1, 1965. Interestingly,

only in the Aug. 1964 version of the basic Air

Force doctrinal manual, AFM 1-1, was the

airlift mission discussed and for the first time.

Miller, Airlift Doctrine, p. 299.

17. Robert F. Futrell, The United States

Air Force in Southeast Asia: The Advisory

356

Notes
Years to 1965 (Washington, D.C.: USAF

Office of Air Force History, 1981), p. 31.

Raymond L. Bowers, The United States Air

Force in Southeast Asia. Tactical Airlift

(Washington, D.C.: USAF Office of Air

Force History, 1983), pp. 21–22. The wounded troops were primarily French Foreign

Legionnaires who had participated in the battles at Dien Bien Phu. They were flown to

Orly Field, Paris, and Oran, Algeria.

Conversation with Col. (Ret.) John Schlight

USAF, July 12, 1997. Colonel Schlight was

assigned to the 374th Wing as a navigator and

served on the crew of one of the Wounded

Warrior flights from Tan Son Nhut to

Tachikawa. His mission carried fifty

amputees on litters back to Japan. Some

French wounded survivors were apparently

treated in U.S. hospitals before being

returned to French control. Bernard B. Fall,

Hell in a Very Small Place: The Siege of Dien

Bien Phu (New York: Vintage Books, 1966),

p. 430–31.

18. Anything, Anywhere, Anytime, pp.

98–99. In an interesting precedent for

Operation New Leaf, the Belgian government at the conclusion of World War II in

Europe had asked the United States to

aeromedically evacuate approximately one

thousand Belgian nationals from its then

colony, the Belgian Congo, to Brussels.

MATS predecessor, the AAF’s Air Transport

Command, developed a plan for such an

operation but recommended that it not be

implemented for two reasons: a single surface vessel could do the job more cheaply

and rapidly (ATC estimated that the move

would require thirty-seven round trips by

C–54 and take a minimum of five weeks) and

that the use of these resources for evacuating

Belgians when U.S. Army personnel eligible

to return to the United States could not do so

because of a lack of transportation would

harm their morale and loose a flood of criticism of ATC and the War Department. Draft

“Plan for Air Transportation of Debilitated

Persons from the Belgian Congo to

Belgium,” n.d., Air Mobility Command

History Office, Scott AFB, Ill. The plan estimated that 25 percent of the evacuees would

be litter patients and the rest ambulatory. Of

the total, “reliable estimates” indicated that

30 to 35 percent might be psychiatric cases

requiring additional medical personnel for

care in transit. The Hashemites were the family that had helped the British against the

Turks in World War and had received two

kingdoms as their reward, Trans-Jordan and

Iraq.

19. Twitchell interview, May 8, 1961.

20. In 1959, the Air Force’s Air Material

Command had three logistic support

squadrons collectively comprising 36 C–124

aircraft. The Strategic Air Command also

employed three strategic support squadrons

comprising a total of 48 C–124s to move

nuclear weapons among its bases. A total of

920 Air Force and Navy transport aircraft

remained outside MATS control after Single

Manager was implemented. Futrell, Ideas,

Concepts, Doctrine, II, pp. 12, 14.

21. Good brief discussions of the activities of these subcommittees’ and the various

issues and recommendations are in Miller,

Airlift Doctrine, pp. 240–74, and Anything,

Anywhere, Anytime, pp. 89–98. The Hoover

Commission of the mid-1950s had, among

other things, recommended that “the level of

MATS peacetime operations be limited to

that necessary to maintain the minimum war

readiness of the command,” and stressed that

other service transportation needs be handled

by commercial transportation lest the result

be “a continuing and expanding military

socialism over all air transportation.”

Quotations from Anything, Anywhere,

Anytime, p. 91. 

22. House, Committee on Armed

Services, Hearings before Special Subcom -

mittee on National Military Airlift, 86th

Cong., 2d sess., pp. 4148–49. The Rivers’

subcommittee hearings are covered in Miller,

Airlift Doctrine, pp. 258–71.

23. Miller, Airlift Doctrine, pp. 269–71.

357

Notes
Army Navy Air Force Journal (Mar. 19,

1960): 29. Miller excerpts the dialogue

between the Air Force Chief of Staff, General

Thomas D. White, and Rivers in which

White makes the extraordinary if possibly

technically correct comment that “MATS is

not a creature of the Air Force.”

24. The specifications called for an aircraft capable of carrying a 70,000–80,000 lb.

payload nonstop across the Atlantic or

Pacific, cruising at 440 knots, operating from

5,000 ft. runways, and airdropping troops and

equipment. It was to incorporate design features to facilitate the loading and offloading

of cargo including an aircraft floor at the

same height as standard truck beds, doors in

the rear of the fuselage that, when opened,

allowed trucks to abut the aircraft floor from

the rear directly for transferring cargo, and a

minimum cargo area of 9 by 10 by 60

ft.–essentially, the C–141A. Miller, Airlift

Doctrine, p. 264

25. During the Berlin crisis of 1961, the

Air Force called to active duty thirty-six

squadrons of the Air National Guard and Air

Force Reserves, including C–124 and C–97

units. Futrell, Ideas, Concepts, Doctrine, Vol.

II, p. 38.

26. Quoted in Miller, Airlift Doctrine, p.

276.

27. Futrell, Ideas, Concepts, Doctrine,

Vol. II, pp. 30, 47. In the Berlin crisis of 1961,

forty-five C–135s that had been diverted

from the KC–135 production line were allocated to MATS.

28. The term medevac was commonly

applied to army helicopters dedicated to

aeromedical evacuation and will be used here

to help differentiate U.S Air Force and Army

aeromedical evacuation units.

29. Following resolution of the forward

aeromedical evacuation issue and the more

favorable attitude toward Army aviation

shown by the Kennedy administration, the

Army procured fixed-wing transports, the

CV–2 Caribous, and twin-engine Mohawk

reconnaissance aircraft. The Caribou was

reportedly capable of carrying twenty litter

patients. The Army also possessed U–1

“Otters” which were used for corps support

and could carry one ton of small bulk cargo

or seven to eight passengers. Futrell, The

Advisory Years, p. 110.

30. Memo for Members of the Armed

Forces Policy Council, Subj: Clarification of

Roles and Missions to Improve the

Effectiveness of Operation of the Department

of Defense, quoted in Wolf, Basic Documents

on Roles and Missions, p. 296. The members

of the Armed Forces Policy Council consisted of the Secretary of Defense (SECDEF),

the Deputy SECDEF, and the Assistant

SECDEFs; the Chairman of the Joint Chiefs

of Staff (JCS), and the JCS members with the

addition of the Commandant of the Marine

Corps, and the General Counsel.

31. Quotations are from “USAF Tactical

Air Concepts for Test and Evaluation,” Dec.

6, 1963, extracted in the STRICOM Joint

Test and Evaluation Task Force Final Report

on Operation Goldfire. AMC History Office

Files, Scott AFB. For a discussion of

Operation Goldfire, see Futrell, Ideas,

Concepts, Doctrine, pp. 185–89.

32. Quotes are from hearings before a

special subcommittee on military airlift,

House Committee on Armed Forces

(Washington, D.C.: U.S. GPO, Oct. 22,

1965), pp. 462–63. Both the Caribou and

Buffalo were built by DeHavilland Aircraft

of Canada and could land on extremely short

runways. The Caribou had a gross takeoff

weight of 28,500 lb., about half that of the

comparable Air Force assault transport, the

C–123, and could carry about half its payload

of 11,000 lb. Bowers, Tactical Airlift, p. 34.

The STRICOM commander, Army Gen.

Adams, seems to have disagreed with the

Army position concluding on the basis of

STRICOM maneuver experience that Air

Force tactical transports should deliver supplies as far forward as possible and that Army

helicopters should make further distribution.

Futrell, Ideas, Concepts, Doctrine, p. 313.

358

Notes
33. Peter Dorland and James Nanney,

Dust Off: Army Aeromedical Evacuation in

Vietnam (Washington, D.C.: U.S. Army

Center of Military History, 1982), pp. 23–24.

Jeffrey Greenhut, “Aeromedical Evacua -

tion,” Chapter VI, pp. 5–6, in “I Have Your

Wounded. The Army Medical Department in

Vietnam,” draft mss., USUHS Library. I am

indebted to Dr. Edward Raines of the Center

of Military History for bringing this unpublished mss., which was prepared by a Center

historian, to my attention. Each chapter is

paginated separately.

34. Divided from the communist Peoples

Democratic Republic of Vietnam at the 17th

parallel of north latitude by agreement at the

Geneva Conference of 1954, the Republic of

Vietnam (RVN, or more commonly identified as “South Vietnam”) comprised only

Cochin China in the south and part of Annam

in the north of the historic three sections of

the country. Vietnam’s communications

infrastructure as a whole had been strained by

the effects of World War II, when the country

had been occupied by the Japanese, and the

Viet Minh insurgency that followed beginning in 1946. Ironically, in view of the more

destructive war to come, an English-speaking

Vietnamese storekeeper in Haiphong tried to

impress on the author in early 1954 what a

terrible impact continuing conflict had on his

country by emphasizing that the insurgency

had gone on by then for eight years! (The

emphasis reflects the vigor with which he

made the point.)

35. The classic case was the annihilation

of Groupement Mobile 100 on Highway 19,

one of the few major west-east roads in the

highlands, between An Khe and Pleiku in

June 1954. Bernard B. Fall, Street Without

Joy (London: Pall Mall Press, 4th ed., 1965),

pp. 207–35. The situation had not changed a

dozen years later. General Neel, the MACV

Surgeon during this period, noted of the period 1965–70 that, “since there was no secure

road network within the combat area of

Vietnam, surface evacuation of the wounded

was almost impossible.” Vietnam Studies:

Medical Support of the U.S. Army in

Vietnam 1965–1970 (Washington, Depart -

ment of the Army, 1973), p.59.

36. Bowers, Tactical Airlift, pp. 3–23,

covers the French period. Futrell, The

Advisory Years to 1965, pp. 3–31, also covers

the French period and the period cited,

including the formation of MACV, pp.

94–100. Also see Futrell, Ideas, Concepts,

Doctrine, Vol. II, p. 287, for a discussion of

MACV’s deactivation. The author observed

the extent of U.S. aid while stationed during

Feb. to June 1954 at Cat Bi Airfield,

Haiphong, while Dien Bien Phu was under

siege and briefly later at Tourane.

37. Another factor may well have been

the Johnson administration’s reluctance to

alarm the U.S. public and lose support for the

President’s domestic program by too visible

deployments of forces to Vietnam.

38. Dorland and Nanney, Dust Off, pp.

23–25. Futrell, The Advisory Years, pp.

85–91, discusses the elements of the initial

Kennedy program for increasing support of

the South Vietnamese counterinsurgency

effort short of U.S. combat units becoming

involved.

39. Dorland and Nanney, Dust Off, pp.

24–25. Initial attitudes of apparent indifference toward the 57th described later support

this conclusion. The VNAF had no dedicated

medevac helicopter units and responded to

medevac requests depending on aircraft

availability, the security of the landing zone,

and “the temperament of the VNAF pilots,”

according to Dorland and Nanney, p. 390.

40. Although MAAG policy restricted

medevac to the U.S. advisors, ARVN commanders sometimes refused to cooperate

unless their wounded were included. The

57th found it expedient to do so because it

was reliant on ARVN communications for

medevac requests and also on the ARVN to

designate secure landing zones.

41. Dorland and Nanney, Dust Off, p. 27.

Greenhut, “Aeromedical Evacuation,” p. 3.

359

Notes
Who was to control helicopter ambulances

was still an open question within the Army

leadership in the mid-1950s. In an exchange

of correspondence between the Continental

Army Command (CONARC) and the Army

G–3 (Operations) in 1955 regarding the

Surgeon General’s comments about apparent

Army aeromedical evacuation planning,

CONARC took the position that “no army

aircraft should be designated specifically as

an ambulance.” CONARC also argued

against the Surgeon General’s proposition

that forward air evacuation for divisions was

best provided by a “minimum” number of

dedicated aircraft under medical control

rather than the division’s organic aircraft.

Memo for CG, CONARC, from Maj. Gen.

Paul D. Adams, Acting ACOFS, DA, Subj:

Medical Air Evacuation, Apr. 27, 1955, covering Disposition Form, Surgeon General for

Deputy G–4 (Logistics), Subj: Medical Air

Evacuation, Feb. 1, 1955; 1st Ind., CG,

CONARC, to Army G–3, May 20, 1955. RG

319, CMH Refiles, “Dust Off,” box 1,

NARA II.

42. Dorland and Nanney, Dust Off, p. 27.

43. Ibid.

44. Ibid.; Greenhut, “Aeromedical Eva -

cua tion,” p. 4.

45. Dorland and Nanney, Dust Off, p. 28.

46. Bowers, Tactical Airlift, p. 85; Futrell,

The Advisory Years, p. 108.

47. Based on the personal experience of

the author who piloted a C–123 based in

Danang, RVN, for a year, 1965–66.

48. Bowers, Tactical Airlift, p. 108.

General Neel, Vietnam Studies. Medical

Support of the U.S. Army in Vietnam

1965–1970 (Washington, D.C.: Department

of the Army, 1973), p. 60.

49. LCDR Bobbi Hovis, NC, USN (Ret.),

Station Hospital, Saigon: A Navy Nurse in

Vietnam, 1963–1964 (Annapolis, Md.: Naval

Institute Press, 1991), pp. 16–17, 108–109,

157. Commander Hovis was dispatched with

the initial cadre to convert a naval dispensary

into a fully equipped naval station hospital.

The hospital staff was also responsible for

treating U.S. Embassy staff, members of the

Agency for International Development, and

allied military personnel and Vietnamese

civilians when possible. In Jan. 1966, the

daughter of Gen. Hguyen Khanh, briefly

prime minister of the RVN, had a large facial

hemangioma (a purple birthmark) removed

at the hospital. In Mar. 1966, the naval hospital was turned over to the U.S. Army and

became the Army 3rd Field Hospital.

Conversation with Commander Hovis, July

17, 1997. Interview with Commander Hovis,

Dec. 8, 1995.

50. The Allison T–56A engines of the

C–130A ran at a constant speed, producing a

very deep and constant roaring noise that

could damage hearing. At the first TAC base

to which the C–130As were delivered, the

463rd Troop Carrier Wing at Ardmore, Okla.,

the flight surgeons required the use of ear

defenders by passengers and ground crews.

Personal knowledge of the author who was

assigned to the 463d in 1955–1956, and flew

on familiarization flights at the Marietta, Ga.,

Lockheed factory.

51. Commander Hovis was a trained

Navy flight nurse and was called upon to

accompany a desperately ill Army major to

Clark on a C–130 that had been diverted to

Saigon from its planned return from Clark

AB to Tachikawa. She was joined by an Air

Force flight nurse who had fortuitously

arrived at Clark from Tachikawa to coordinate the aeromedical evacuation schedule for

the southeast Asia system and “deadheaded”

(that is, performed no flight duties) on the

diverted aircraft to Saigon. Hovis, Station

Hospital Saigon, 142–43. Hovis conversation. Apropos the C–130A’s noise level previously mentioned, Commander Hovis notes

being issued wax earplugs for her return

flight to Saigon from Clark on a C–130A.

Hovis, Station Hospital Saigon, p. 144.

52. Bowers, Tactical Airlift, p. 396.

53. Of the 105 officer spaces allocated to

MACV at its creation in Mar. 1962, the Air

360

Notes
Force got 22, the Navy and Marines got 29,

and the Army got 54; the J–2 (Intelligence)

was an Air Force colonel, but the Air Force

got none of the key operational positions and

only one of the five general officer billets, the

J–5 (Plans). He tended to be “out of loop”

operationally because, in accordance with

Army practice, Gen. Harkins, the first

MACV Commander, relied on his J–3

(Operations), an Army officer. As a result, the

J–5 was often outside daily MACV activities,

a situation that was worsened by the physical

separation of his office in a different part of

Saigon from the other major MACV staff

locations. Futrell, The Advisory Years, pp. 97,

102; Bowers, Tactical Airlift, pp. 103–4.

54. The Army’s bias was evident even to

a presumably neutral (Navy) observer like

Admiral Felt, the Commander-in-Chief

Pacific Command (CINCPAC) who commanded the major unified command in the

Pacific. Felt asserted to Secretary of Defense

MacNamara and General Taylor that Army

advisors deliberately neglected to forward air

support requests at times because they wanted to use Army aircraft to further Army doctrinal concepts. MacNamara and Taylor both

rejected the criticism. Futrell, The Advisory

Years, pp. 207–8.

55. Anticipating possible future U.S.

combat operations that by law no MAAG

could command, PACOM had established an

advanced echelon of 13th Air Force in

Saigon in Nov. 1961. This ADVON (which

became 7th Air Force in Feb. 1966) was designated as the air component of MACV when

it was activated in early 1962. However,

MACV kept tight control of air operations

and consistently resisted the centralization of

airlift the Air Force sought. See Futrell, The

Advisory Years, pp. 111–12, et seq.; also John

Schlight, The United States Air Force in

Southeast Asia. The War in South Vietnam:

The Years of the Offensive 1965–68

(Washington, D.C.: Office of Air Force His -

tory, 1988), Chapter 1s.

56. Bowers, Tactical Airlift, pp. 109–110.

In Jan. 1963, Admiral Felt, CINCPAC, recommended to the JCS that all Caribous

should “be included in the established airlift

system,” and, two months later, the JCS

approved Felt’s position. He formally reiterated it in June, but the MACV managed to

keep the Caribous’ operations conducted

almost entirely for corps-level support.

Bowers, Tactical Airlift, pp. 121–22.

57. Futrell, The Advisory Years, p. 207. In

fairness, the first MACV Commander-designate, General Paul Harkins, had sought to

give the J–3 (Operations) position to an Air

Force officer but had been overruled by

Secretary of Defense MacNamara who wanted the Army to have the J–3 billet. Futrell,

The Advisory Years, p. 97.

58. MacNamara seems to have viewed

the Army as an innovative force within the

U.S. military because of its new airmobile

concept, and he obviously was fascinated by

the emerging counterinsurgency doctrines as

was President Kennedy. Personalities also

undoubtedly played a role in MacNamara’s

perceptions and helped condition his decisions. MacNamara had recommended

Harkins to the President to head the new

command, and Harkins was a protégé of Gen.

Maxwell Taylor, who had been called out of

retirement to be President Kennedy’s military

advisor. Whether he was the source of the

recommendation or not, Taylor’s strong support can be taken for granted. Taylor had

been the most severe uniformed critic of the

emphasis that the Eisenhower administration

placed on nuclear deterrence at the expense

of the Army’s capability to fight “limited

wars” like the Korean War, and he chaired a

Special Working Group on Counter -

insurgency that was created by President

Kennedy to fuse all governmental efforts to

combat the Viet Cong insurgency in South

Vietnam. On the other hand, the Air Force

Chief of Staff, Gen. Curtis E. LeMay, was the

former commanding general of the Strategic

Air Command and personified the focus on

the previous administration’s reliance on the

361

Notes
threat of nuclear war to maintain U.S. security. Futrell, The Advisory Years, pp. 97, 104–5.

59. By March 1966, the 315th Troop

Carrier Group had gone through two transformations to become the 315th Air

Commando Wing.

60. Bowers, Tactical Airlift, p. 241–42.

61. Bowers, Tactical Airlift, pp. 282–83.

62. The circumstances of this agreement

are discussed in Schlight, The Years of the

Offensive, pp. 122–24.

63. Bowers, Tactical Airlift, pp. 186–87.

64. TAC CORONA HARVEST Report

on Tactical Airlift in SEA, 1965–68, Vol. IV:

Aeromedical Evacuation (File: K417.03-4,

Vol. IV. HRA), pp. 35a–35b. Although not

“officially” a TAC report, the document was

submitted over the signatures of the commander of the USAF Tactical Airlift Center

and Gen. Momyer, Commander TAC, to the

Corona Harvest project office. Since the document was intended for internal Air Force use

only, the authors obviously were more blunt

than they might otherwise have been.

65. For example, occasionally, a patient

suffering from some mild illness might be

evacuated with a group of seriously wounded

from ground action. In one case, such an individual was reportedly given a Purple Heart

while lying on a stretcher at a CSF in spite of

his protests. Interview, Dr. Robert Joy,

Professor Emeritus, Medical History,

USUHS, July 31, 1997. Carl Von Clausewitz,

the Prussian philosopher of war, would

undoubtedly have recognized these events as

resulting from the “friction” inherent in any

conflict, which he had conceptualized in his

writings. In spite of the excellent work done

by specialists like Peter Paret, Clausewitz

requires an investment of time that few nonspecialists are usually willing to invest. For a

short brilliant summary of his ideas, see

Christopher Bassford, Clausewitz in English:

The Reception of Clausewitz in Britain and

America, 1815–1945 (New York: Oxford

University Press, 1994), Chapter II, “Clause -

witz and His Works.”

66. Quotation is extracted from the endof-tour report of the 7th Air Force Surgeon,

Col. Stanley Bear, for the period June

1967–May 1968. TAC CORONA HARVEST Report Aeromedical Evacuation,

1965–1968, p. 6. 

67. Neel, Medical Support of the U.S.

Army in Vietnam, pp. 60–62. There were also

U.S. Air Force hospitals in Thailand where

Air Force fighter-bombers and supporting

aircraft were stationed for attacks on North

Vietnam during Operation Rolling Thunder.

Interview Col. (Ret.) Russell Rayman, USAF

MC. Colonel Rayman commanded one of

such hospitals at Udorn, Thailand. For a discussion of Rolling Thunder, see Futrell, The

Advisory Years, p. 22, et passim.

68. Neel, Medical Support of the U.S.

Army in Vietnam, p. 72.

69. Interview of General Neel, Jr., USA

MC (Ret.), U.S. Army Senior Officer Oral

History Program, Vol. I, pp. 88–89. Neel says

essentially the same thing with more precision in an earlier interview while still on

active duty. See Oral History interview conducted by John Bullard at Ft. Sam Houston,

Tex., Mar. 3, 1977. (File: K239.0512-966,

77/013/03. HRA.) Gen. Neel was MACV

Surgeon twice: July 1965–July 1966 and

Aug. 1968–July 1969. During the first half of

the latter tour, he was USARV Surgeon and

Commander of the 44th Medical Brigade, the

central medical organization in South

Vietnam.

70. Quoted in TAC CORONA HARVEST Report on Aeromedical Evacuation,

1965–1968, p. 38b.

71. Dorland and Nanney refer to the Dak

To episode although in a way that suggests

they were unaware that Air Force tactical

aeromedical evacuation (AE) doctrine called

for mobile CSFs to routinely receive and hold

casualties from ground combat for tactical

AE, which the Air Force believed was its

responsibility. In Vietnam, as discussed later,

this responsibility was often assumed by

Army medevac helicopters. Dust Off, pp.

362

Notes
59–60. Greenhut discusses the Dak To battle

in some detail in his mss. but says nothing

about the Air Force roles. “I Have Your

Wounded,” Chapter IV, pp. 29–32.

72. Neel, Medical Support of the U.S.

Army in Vietnam, pp. 73–74. Greenhut discusses the origins of the in-country regulating

system, in “I Have Your Wounded,” Chapter

IV, pp. 17–18.

73. Neel, interview Mar. 3, 1977, pp.

19–22

74. Greenhut, “Aeromedical Evacua -

tion,” pp. 2–3, 6; Dorland and Nanney, Dust

Off, pp. 78–79.

75. The extreme case was the 3d Surgical

Hospital at Dong Tam in the Delta, which

was mortared twice in Nov. 1966 and suffered thirteen separate attacks in 1968 that

damaged the hospital area. Neel, Medical

Support of the U.S. Army in Vietnam, p. 67.

76. Neel, Medical Support of the U.S.

Army in Vietnam, pp. 76–77.

77. Ibid., pp. 70–71.

78. TAC CORONA HARVEST Report

on Aeromedical Evacuation, 1965–1968, pp.

4–5.

79. In its after-action evaluation, TAC

noted that no 7th Air Force document of the

period made any mention of an in-country

aeromedevac responsibility. TAC CORONA

HARVEST Report on Aeromedical

Evacuation, 1965–1968, p. 35.

80. Ibid., pp. 35c–35d.

81. Ibid., pp. 7, 16.

82. Quote is from TAC CORONA HARVEST Report on Aeromedical Evacuation,

1965–1968, pp. 38c–39. An anonymous but

evidently senior official reviewing the TAC

report annotated it extensively including an

occasional vigorous disagreement written in

the margin; for example, apropos the preceding quotation, he twice underlined the word

“threat”, following it with a double question

mark and the comment “a help!” Beside the

author’s comment that, as the RVN patient

load increased the “diversion of more and

more C–130 aircraft to scheduled medevac

duty became a serious concern,” the anonymous reviewer wrote “This is a TAC mission!! Diversion?!” TAC CORONA HARVEST Report on Aeromedical Evacuation,

1965–1968, p. 35f. The author identified

other factors that weakened the tactical

aeromedical evacuation effort, and these factors originated with the Air Force itself,

including eager but inexperienced flight nurses, the lack of sufficient numbers of SSB/HF

radios, uncooperative hospital commanders

and unnecessary red tape constraining AMES

personnel, and corrupt supply practices–a

CSF officer on temporary duty at Clark AB

reported reading a Clark “Medical Supply

Operation Procedure” that directed that serviceable litters be retained locally and unserviceable litters be shipped to Vietnam. TAC

CORONA HARVEST Report on

Aeromedical Evacuation, 1965–1968, p. 26.

83. TAC CORONA HARVEST Report

on Aeromedical Evacuation, 1965–1968, p.

39. For example, Maj. Gen. (Ret.) Benjamin

R. Baker, USAF MC, a former Surgeon of

the United States Air Force in Europe

(USAFE), long after the Vietnam War,

argued the case for using aeromedical evacuation to permit reducing the size of forward

medical establishments, although he recognized that, if carried to the extreme, this

would create substantial training and replacement problems. He attributed the Army’s

unwillingness to look seriously at the issue in

the 1960s due to the conservatism of the

Army Surgeon General, Leonard Heaton,

and the usual argument that aeromedical

evacuation took personnel out of theater and,

hence, tended to drain combat strength. Oral

History interview by Dr. George M. Watson,

Jr., May 9. 16, 1990. (File: K239.0512-2019,

HRA.)

84. TAC CORONA HARVEST Report

on Aeromedical Evacuation, 1965–1968, p.

39.

85. The 903d AMES treated and moved

more than ten thousand patients in the thirty

days following its beginning on Jan. 30, not

363

Notes
all of whom, of course, were evacuated out of

country. Bowers, Tactical Airlift, p. 400.

86. For example, General Baker, the former Air Force Deputy Surgeon General, took

this position in discussions with General

Heaton, the Army Surgeon General, with

regard to how to use aeromedical evacuation

to greatest advantage during the Vietnam

conflict. According to Baker, Heaton disagreed because of the potential drain on

Army manpower in-country, a position that

Baker implied was adopted by the Army

because of Heaton’s “bias,” but which was

actually a long-standing concern in the Army

about “overevacuation.” Interview of Maj.

Gen. (Ret.) Benjamin R. Baker, USAF MC,

May 9, 16, 1990. USUHS Library. It will be

remembered that General Tunner, 315th Air

Division Commander during the Korean

War, had suggested flying casualties directly

back to Japan from the combat areas but been

turned down by the 8th Army Surgeon.

87. Ltr, Col. Earl W. Brannon, 7th Air

Force Surgeon, to MACV (MACMD), Subj:

Cessation of Designations of Evacuation of

Patients to CONUS, 15 Feb, 1967. (File:

168.7082-135, HRA.)

88. Ibid.

89. Ltr, Col. Stanley Bear to Col. John R.

Archdeacon, Director, Hospital Services,

Clark, Dec. 27, 1967; Ltr Archdeacon to Bear,

Jan. 15, 1968. (File: 168.7082, M.S. White

Col lection, HRA.) In his letter, Bear recalls for

Archdeacon a conversation they had, presumably by telephone, on the 20th in which Bear

told the latter that medical personnel of Navy,

Marines, and Army were “upset about the

number of their patients that are being remov -

ed from air-evacuation aircraft at Clark ... and

retained for further stabilization.” Bear provided a list of twenty such patients asking Arch -

deacon to “check on” them because “our credibility is being questioned,” and he was concerned that “the good relations which had been

built up with the Army and Navy could be

jeopardized.”

90. An analysis was conducted recently of

the data provided in the Archdeacon letter by

an experience Army doctor who had served

in Vietnam. His conclusions support a lay

reading of Archdeacon’s stated reasons that

appear persuasive. Ltr, Dr. Robert T. Joy,

MD, Professor Emeritus, Medical History,

USUHS, to the author, Aug. 5, 1997.

91. For example, Ltr, Major Irwin A.

Silberman, USAF MC, Chief of Aeromedical

Services, 347 USAF Dispensary, Yokota Air

Base, Japan, to Surgeons, 5th Air Force,

PACAF, and MAC, Jan. 30, 1968; Ltr with

attached study, Col. Donald N. Vivian, USAF

MC, Commander, Tachikawa Hospital, July

15, 1968; Ltr, Brig. Gen. A.A. Hoffman,

Commander, Malcolm Grow Hospital,

Andrews AFB, Maryland, to Maj. Gen. M.S.

White, PACAF Surgeon, Jan. 8, 1968. The

School of Aviation Medicine also conducted

a study of selected aspects of aeromedical

evacuation in PACOM including a discussion

of patient “stabilization” (quotes in the original index.) Capt. John E. Murphy, USAF

MSC, An Exploratory Study of Selected

Medical Aspects of the Aeromedical

Evacuation System in the Pacific Area

(Headquarters Aerospace Medical Division,

Mar. 1968), in HRA.

92. Extension of the roughly 5,000 ft. runways at Tachikawa had been blocked for a

decade by local farmers. Personal knowledge

of the author. MAC CORONA HARVEST

Report, Aeromedical Evacuation, 1968–

1969. (File: K300.04-27, 1 Apr. 1968–31

Dec. 1969, HRA), pp. I-4-6. (The sections of

the report are paginated separately.)

93. MAC CORONA HARVEST Report,

Aeromedical Evacuation, 1968–1969. Ibid,

p. I-7.

94. HQS, MATS, Modernization of the

Domestic Aeromedical Evacuation System,

Apr. 15, 1965, Amended HQ, USAF (June

15, 1965), pp. 1–6, et passim.

95. Aeronautical Evacuation Division,

Office of the Command Surgeon, MAC

CORONA HARVEST Report on

Aeromedical Evacuation in SEA, 1 January

364

Notes
1965–31 March 1968 (Dec. 31, 1969), p. II10. This report also has separately paginated

chapters. It was approved by Brig. Gen.

Harold Funsch and the MAC commander,

Gen. Jack Catton.

96. Disposition Form, Subj: Aeromedical

Training for ANC Officers on Active Duty,

from Colonel Mildred I Clark, to the Director

of Professional Services, Mar. 3, 1964. I am

indebted to Maj. C. J. Moore, USA, ANC, the

ANC historian at the Center of Military

History for a copy of this letter.

97. Quote from John P. McGann, M.D., et

al., Medical Systems Analysis, Aeronautical

Evacuation System, Dec., 1968, in MAC

CORONA HARVEST Report, Aeromedical

Evacuation, 1968–1968 (July 16, 1970), p. I10. The chapters are paginated separately,

and this report was approved by the same

command-level personnel as the preceding

MAC report on the subject.

98. MAC CORONA HARVEST Report,

Aeromedical Evacuation, 1968–1968, p. IV30.

Chapter Seven

1. The Corona Harvest format included a

discussion of personnel issues, and both the

MAC and TAC reports on aeromedical evacuation indicate some problems arose in the

training and manning areas. Shortages of personnel as the aeromedical evacuation system

expanded caused MAC to generate two programs for augumenting the Pacific division,

Cold Dove, which drew upon AE personnel

in other MAC organizations, and Patch Up,

which drew AE personnel from other Air

Force commands. MAC CORONA HARVEST Report, Aeromedical Evacuation,

1968–1969, p. IV–V-1.

2. Cecil L. Reynolds, MAC Aeromedical

Airlift Support of Southeast Asia Operations

(1964–1971) (Scott AFB, IL: Office of

Military Command History, Nov. 1, 1972),

Appendix II, Section V, p, 124.

3. MAC Aeromedical Airlift Support, p.

117. The PACAF surgeon noted long after

the event that he had “trouble” with the Army

because it was designating nondetoxified

drug abusers for aeromedical evacuation,

which was contrary to Air Force policy.

Telephone conversation with Maj. Gen.

(Ret.) Larry Smith, USAF MC, Aug. 13,

1997.

4. Coy F. Cross, II, MAC and Operation

BABYLIFT: Air Transport in Support of

Noncombatant Evacuation Operations(Scott

AFB, Ill., Headquarters Military Airlift

Command, 1989), p. 10.

5. MAC and Operation BABYLIFT, p. 12.

6. Lt. Col. Gerald W. Noga, commander,

9th AEG, after-action reports: Operations

Babylift, Frequent Wind, New Life, Eagle

Pull, the Mayaguez affair (Clark Air Base,

Philippines: 9th AEG, June 1975), p. 2. File:

Aeromedical Evacuation, Historical Office,

Office of the Surgeon General.

7. Daly made an unsanctioned flight to

Danang in late March, taking off from Tan

Son Nhut without clearance and returning

with 268 people –but only two women and

one baby-jammed into the airplane and wheel

wells. When Operation Babylift was

announced, Daly unilaterally announced that

a World Airways 747 would carry 458

orphans out of Saigon, but was thwarted by

the U.S. ambassador. However, he did carry

the first load of 54 orphans, together with 27

adult escorts, from Saigon on Apr. 2, characteristically ignoring the Tan Son Nhut control

tower’s advisory that the runway was closed.

Six of the adult escorts had neither passport

nor exit visa. Daly’s general attitude seems to

be captured by his comment to reporters concerning the Danang flight: “People who

should have been doing something about it

sat on their asses and refused to move.” Coy,

MAC and Operation BABYLIFT, p. 46.

8. David Butler, The Fall of Saigon:

Scenes from the Sudden End of a Long War

(New York: Simon & Schuster, 1985), p. 155.

Butler chronicles Daly’s activities vividly on

pp. 155, 162–70, and 221–22.

365

Notes
9. Butler, The Fall of Saigon, p. 33.

10. Lt. Col. Regina C. Aune, USAF NC,

“Reflections on a Humanitarian Mission 20

Years Later: Operation BABYLIFT,”

Military Medicine 160 (Nov. 1995): 585.

Aune was assigned to the 10th AES based at

Travis, which was in the process of merging

with the 9th AES pursuant to the centralization of worldwide AE under MAC.

11. Cross, MAC and Operation BABY -

LIFT, p. 39.

12. Cross, Ibid., pp. 36–38.

13. Cross, Ibid., p. 45.

14. Cross, Ibid., p. 15. The documentation

for this is a transcript of a telephone conversation between MAC DCS/Operations and

the commander of the Pacific Exchange

System in which the PES commander related

his conversation with a State Department

official.

15. Noga, after action reports: Operation

BABYLIFT, p. 2.

16. Cross, MAC and Operation BABY -

LIFT, pp. 49–50. For example, a World

Airways 747 landed in Los Angeles on Apr.

12 with 330 orphans, several of whom were

seriously ill and another 20 severely dehydrated. One three-month-old child had died

enroute from Clark to Los Angeles. Twentytwo children were scheduled to continue on a

Scandinavian Air Service (SAS) to Norway

for adoption by Norwegian families if their

health permitted. Another 220 children were

enroute to Fort Benning, Ga., for adoption by

U.S. families. Pacific Stars and Stripes (Apr.

14, 1975): 1. 

17. Robert D. Schulzinger, A Time for

War: The United States and Vietnam, 1941–

1975 (New York: Oxford University Press,

1997), p. 307.

18. 9th AEG OPLAN 1-72, 9th AEG

OPLAN FOR THE REPATRIATION AND

RETURN OF PRISONERS OF WAR

(EGRESS RECAP), Sept. 1, 1972, printed in

Narrative Reports of “Operation

Homecoming” (Clark Air Base: 9th

Aeromedical Evacuation Group (PACAF),

1973), AMC History Office, Scott AFB, Ill.

(cited hereafter as Operation Homecoming

Reports).

19. Col. Leonard W. Johnson, after-action

report of the overall aeromedical evacuation

coordinator, Apr. 1973, in Operation HOMECOMING Reports, p. 21.

20. By 1973, the treatment of U.S. POWs

was well known from a variety of sources

including foreign and U.S. visitors to Hanoi,

some of whom opposed the war but were

concerned about the plight of the POWs, and

several U.S. military men who were released

as a gesture in 1969, one of whom was in the

author’s National War College Class in

1970–71.

21. CORONA HARVEST Report, Aero -

medical Evacuation, 1968–1969, p. IV–I-25.

22. Aeromedical Support of Project

Homecoming, p. 1. Interview with Col. (Ret.)

Russell Rayman, USAF MC, July 11, 1997.

Colonel Rayman was assigned to the USAF

hospital at Clark AB, participated in the final

C–141 pickup of released POWs at Gia Lam

on March 27, 1975, and briefly commanded

the 9th AEG following Colonel Johnson’s

reassignment. Coordination was not accomplished without significant senior involvement. In a demonstration of the efficacy of

the MAC worldwide command and control

system-and symbolic of the establishment of

the MAC-directed worldwide aeromedical

evacuation system-the commander of 22d

Air Force was in direct contact by radio with

C–141s orbiting near Hanoi before they were

cleared to land for POW pickup. Telephone

conversation with Col. (Ret.) John Doglione,

USAF, Sept. 22, 1997. Colonel Doglione

later commanded the parent C–9 unit, the

375th Aeromedical Airlift Wing at Scott

AFB. However, on Feb. 12, 1973, he was a

C–141A squadron commander from Travis

AFB flying the first C–141A scheduled to

land at Gia Lam Airport, and he was receiving instructions personally radioed from the

22d Air Force commander, Maj. Gen. John

Gonge. The author was Deputy Commander

366

Notes
for Operations of the 60th Military Airlift

Wing at Travis AFB, the headquarters of 22d

Air Force, and was told of this by the operations staff.

23. Aeromedical Evacuation Missions,

Operation Homecoming (formerly Egress

Recap), pp. 25–26. Seven of those freed by

the North Vietnamese and Viet Cong were

allied military and civilians. Two were Thai

military, two were Philippine civilians, two

(one of them a woman) were German civilians, two were Filipino civilians and one was

a Canadian civilian. The last was the only

allied person to be evacuated to the U.S. during Phase II of the operation. 

24. Aeromedical Evacuation Missions, p.

25; Lt. Col. William Runkle, USAF, MC,

Report on Phase I Homecoming Mission

#2311, Apr. 1, 1973, Operation HOMECOMING Reports, pp. 135–39. Runkle was

one of the flight surgeons detailed to provide

medical escort on the C–9s moving exPOWs from Tan Son Nhut to Clark AB. He

flew on one of two Hueys to Xom Tieu in the

Delta area of South Vietnam to pick up a U.S.

Army captain who had been a helicopter pilot

prior to his capture. Runkle’s normal assignment was as hospital commander at Ubon

Royal Thai Air Force Base, and his was the

last scheduled POW pickup. After-action

report of the overall aeromedical evacuation

coordinator, pp. 21, 152. Major Richard E.

Gordon, “MAC Aeromedical Support of

Southeast Asia,” p. 72. (File: M-U 43122

G664m, Air University Library (AUL),

Maxwell AFB, Ala.)

25. Aeromedical Support of Project

Homecoming; Report of Hanoi Special

Mission, Cardiac Requirement, pp. 17–18,

73–75.

26. Lt. Col. Robert C. Hauver, USAF

MC, Report of Phase I Homecoming Mission

from Hanoi, Feb. 12, 1973, p. 46. Gordon,

“MAC Aeromedical Support of Southeast

Asia,” p. 21.

27. LCDR Michael Stenberg, USN, MC,

and Cdr. R. Paul Caudill, Jr., Report on South

Pickup (Gia Lam) Phase I, Mar. 9, 1973,; Lt.

Col. Frank S. Pettyjohn, USA, MC, Memo,

to U.S. Army Aeromedical Research

Laboratory, Subj: Delayed Homecoming

Mission Report (Initial Report Lost), Oct. 29,

1973 (mission was flown Mar. 7, 1973;

Pettyjohn was an Army cardiologist who was

chief of cardiovascular medicine at the laboratory in Oct. 1973); Major Jose Trabal,

USAF MC, Phase I Homecoming Mission,

Feb. 12, 1973; Aeromedical Support of

Operation Homecoming; Operation HOMECOMING Reports, pp. 77–78, 80–823,

42–43, 15–18.

28. Quotations from Caudill and

Stenberg, Report on South Pickup (Gia Lam)

Phase I, p. 79. One of the pilots who flew a

Phase II mission to CONUS recorded marveling at the POWs’ collective spirit and evident pride in the United States and what it

stood for which compelled him to take a

“long look” at himself and conduct “some

deep soul-searching.” Captain Paul Cronin,

quoted in Anything, Anywhere, Anytime, p.

149. 

29. Aeromedical Support of Operation

Homecoming, p. 23.

30. Interview with Lt. Col. (Ret.) Olivia

Theriot, USAF NC, Aug. 12, 1997. Col.

Theriot was stationed at Clark as a member

of the 902d AES. References to the duration

of the fighting in Saigon and the strength of

the VC attack on Tan Son Nhut are from

General Westmoreland’s memoirs. William

C. Westmoreland, A Soldier Reports (Garden

City, NY: Doubleday & Company, 1976), pp.

323–28.

31. Interview with Lt. Gen. (Ret.)

Kenneth E. Pletcher, USAF MC, Aug. 2,

1997. Whatever the factors in AF headquarters’ thinking that militated against the C–9A

procurement mentioned in the last chapter,

the decisive factor in overcoming the Air

Force reluctance was almost certainly

President Johnson’s praise for the aeromedically configured aircraft that he toured at

Cam Ranh Bay in Vietnam in Oct. 1966.

367

Notes
Gen. Westmoreland had set up a visit to the

AF hospital there and directed his chief of

staff to transfer some Army patients from the

Army 3d Field Hospital at Nha Trang to the

AF hospital so that the president could see a

“representative group of hospital patients.”

Westmoreland, A Soldier Reports, p. 191.

32. The “continuum” comment is from

MAC CORONA HARVEST Report,

“Strategic Airlift in SEA, 1 January 1965–31

March 1968,” Dec. 31, 1969, p. V-25 (File:

K300.04-27, Jan. 1965–Mar. 1968, vol. I,

HRA.) Other quotations are from Anything,

Anywhere, Anytime, p. 164.

33. Anything, Anywhere, Anytime, pp.

154–7, 164–5.

34. Anything, Anywhere, Anytime, p. 164.

Betty R. Kennedy, Hq, AMC/Historical

Office (HO) Point Paper, Subj: Aeromedical

Evacuation Historical Precedents, Sept. 23,

1994; and Betty R. Kennedy, An Illustrated

History of Scott AFB, 1917–1987 (Scott

AFB, IL: MAC HO, Sept. 1987), p. 122.

35. Colonel Aune, another nurse, and a

medical technician, all from the 10th, were

temporarily assigned to Clark to provide help

during the transition of the 9th AEG from

PACAF to MAC control as MAC assumed

worldwide responsibility for aeromedical

evacuation. Telephone conversation with

Colonel Regina Aune, Sept. 22, 1997.

36. In an interview long after the events,

Brig. Gen. (Ret.) Claire Gorrecht, USAF NC,

who was Chief Nurse of the 10th AEG the

parent organization of the MAC AEGs at

Clark and Yokota in the late 1960s, commented that her nurses never got adequate crew

rest. Interview, August 13, 1997. General

Gorrecht later became Chief Nurse of the Air

Force. At that, MAC may have been better

than theater organizations. In an undoubtedly

hyperbolic remark, Col. Theriot remarked that

she had not known what crew rest was until

she got into MAC after first serving in the

PACAF 902 AES. Theriot Interview.

37. Interview with Dr. Russell Rayman,

July 11, 1997. In Oct. 1946, there were 24

hospitals in the U.S. zone of Germany and

four hospitals still in Belgium and France

supporting three hundred thousand troops in

Europe. A reduction in U.S. forces programmed to be accomplished by Feb. 1,

1947, was to be paralleled by a reduction to

seventeen hospitals in the U.S. zone. Minutes

of the Command Surgeon’s Conference,

Headquarters United States Air Forces in

Europe, Oct. 18, 1946, p. 33. RG 341, Entry

44, box 314, NARA II.

38. For example, in May and June, 1953,

the 1st Aeromedical Evacuation Flight operating as part of 12th Air Force flew 43 scheduled missions and 44 special or emergency

missions, which transported 465 patients to

hospitals in Germany and returned 63 recovered patients to their home stations. Patients

were embarked at points in France including

Bordeaux, La Rochelle, and Paris, Brussels,

Pisa, Ankara, Rome, Algiers, Madrid, and

Trieste among others. Maj. Stanley B.

Westort, USAF MSC, “History of 1st

Aeromedical Evacuation Flight from 1 May

1953 to 30 June 1953,” pp. 4, Appendices 1

and 2. (File: K-MED-1-HI, May–June 53,

box 40, HRA.) The appendices summarize

air evacuation completed and show point of

embarkation and point of debarkation for

each patient. The three debarkation points

were essentially Wiesbaden, Frankfort, and

Landstuhl with the first two receiving the

vast bulk of patients. One patient went to

Stuttgart and another to Bitburg.

39. Memo, Col. M. S. White, MC, ATC

surgeon, for the ATC chief of staff, Subj:

Overseas Medical Air Evacuation, January 8,

1947. AMC HO. During 1965, before the

massive U.S. buildup in southeast Asia (SEA)

had gotten fully underway, aeromedical evacuees from the Pacific totaled 8,072, and 3,758

from Europe. For the next five years, the average number of evacuees from Europe per year

averaged just under 3,000, an average

decrease of 800, whereas aeromedical evacuees from SEA for the next five years averaged just under 34,000 per year. Reynolds,

368

Notes
MAC Aeromedical Support of SEA

Operations, p. 122. MAC CORONA HARVEST Report Aeromedical Evacuation in

SEA, 1965–1968, p. D-2. USAFE Com mand

Surgeon’s Conference, p. 23. The Euro pean

theater in 1946 did not encompass the geographic area for which the U.S. European

command was later to be responsible because

a Mediterranean command that included Italy

and other littoral states still existed.

40. Annual Report of the Assistant to the

Secretary of Defense (Health and Medical) to

the Secretary of Defense, June 30, 1952, pp.

50–52. RG 264, Entry 36, box 12, NARA II.

41. For example, the U.S. mission to

NATO developed a chart in the early 1980s

that showed there were more than 100 NATO

committees, subcommittees and working

groups considering various aspects of NATO

military communications. Copy in possession of the author. 

42. Telephone conversation with Maj.

Gen. (Ret.) William Greendyke, USAF MC.

General Greendyke was assigned to Europe

initially to be the USAFE surgeon but in late

1984 was designated the first full-time

USEUCOM surgeon. Previous to that time,

the senior surgeon of the three service components of the European command held the

post as an additional duty. 

43. Interview with Lt. Gen. Kenneth E.

Pletcher,USAF MC, Aug. 2, 1997. Pletcher

had previously served as an attaché in the

United Kingdom and was sent back there

specifically to identify sites for hospitals to

support SAC bomb wings.

44. Interview with Lt. Gen. (Ret.) Paul W.

Myers, USAF MC, Aug. 11, 1997; Myers

was Air Force surgeon general at the time.

Interview with the Honorable Ron Richards,

Principal Director, Health Services,

Operations, and Readiness, OASD, Health

Affairs, Oct. 2, 1997. Richards remembered

Beary’s testimony as that there were beds

sufficient to treat only one in five casualties. 

45. Richards interview. Richards recalled

the Navy as balking at procuring hospital

ships and noted that HA had to use the

Defense Resources Board (DRB), an OSD

body that reviewed service budgets and made

final budget decisions, as a way of putting

pressure on the services to change their budget priorities. For example, in 1985, the DRB

issued a program decision memo that

reestablished military readiness spending that

the services had either cut or postponed. Lt.

Col. John R. Beaty, USAF, et al., “Planning

for the Mobilization of the Nation’s Medical

Resources,” p. IV-7. NDU, 1985, USUHS

Library.

46. Richards interview. Richards indicated that Mayer focused almost exclusively on

medical readiness and noted that Mayer was

not interested in issues like managed care or

other ways of controlling the costs of providing health care to the active and retired force

and their dependents. However, Secretary

Weinberger was concerned about such costs,

and, whatever his priorities, Mayer was

involved in changes to the ways in which

medical care was provided to dependent

civilians. Mayer’s apparent solution was to

contract out dependent medical care. “DoD

Medical Plan to Send More Kin Off Base for

Care,” Air Force Times (Sept. 30, 1985): 1,

18. Interview with Brig. Gen. (Ret.) John

Johns, Oct. 7, 1997. Resource allocation over

hospital construction was also centralized in

OASD/HA during Mayer’s’ tenure, a move

growing out of a recommendation from a

blue ribbon panel on hospital sizing that

stirred controversy in the services’ medical

departments. Maj. Chester H. Morgan,

Congressional Hearing Resume, Wartime

Medical Readiness and Planning, Sept. 19,

1985. Copies in the possession of General

William H. Greendyke, USAF MC. I am

indebted to General Greendyke for access to

his papers. Greendyke interview.

47. Greendyke interview. The USEUCOM staff dissected Mayer’s testimony on

military medical readiness before a subcommittee of the House Armed Services

Committee on Sept. 18–19, 1985, for the

369

Notes
command surgeon. It compared Mayer’s

statements with the facts known in the theater. Even allowing for a staff member’s

“best case” analysis–that is, one most favorable to USEUCOM–this staff product does

support the critics’ allegations when it is

compared with summaries of Mayer’s testimony. Analysis of Testimony of Dr. Mayer

before the United States Congress on 18 and

19 September 1985, n.d.; Colonel Frank J.

McKeown, Congressional Hearing Resume,

September 18, 1985; Morgan, Congressional

Hearing Resume, September 19, 1985;

Greendyke papers.

48. Interview with Maj. Gen. (Ret.)

William H. Greendyke, MC, USAF, Aug. 24,

1997. According to General Greendyke,

Colin Powell, then assistant to the chairman

of the JCS, told him that Mayer was exaggerating the deficiencies in European medical

support in order to win Congress’s support for

increased funding that could be allocated to

medical readiness in the Pacific. On the other

hand, Gen. Richard Lawson, USAF, the former deputy commander of the U.S. European

command (DCINCEUR) in an interview long

after the events in question indicated that he

had not felt when he became DCINC in 1984

that the command’s medical readiness was

sufficient to support actual conflict and thereby demonstrate to Soviet planners that NATO

forces were capable and intent on resisting a

Warsaw Pact attack. Drawing on his SAC

background, General Lawson commented

that General LeMay had taught him that you

deterred someone only if you could demonstrate to them that you were capable of doing

what you said. Interview with General

Richard Lawson, USAF, July 29, 1997.

49. Mayer had administered the California

Department of Health for then governor

Ronald Reagan. Richards interview. Conse -

quently, Mayer probably had more internal

“clout” with senior figures in the administration than did his predecessors because of

Richard Meiling’s warm relationship with

Sec re tary of Defense George C. Marshall. I

am indebted to Dr. Dale Smith, Director of

Medical History at USUHS, for first bringing

Mayer’s’ close personal relationship with

President Reagan to my attention. Mayer

became ASD/HA in Dec. 1983, two months

after the Beirut bombing. Interview with Dr.

John Mazzuchi, DASD/HA for clinical services, Oct. 2, 1997. For more detailed information on Mayer’s background, see Tom Phil -

pott, “DoD Health Chief Still Makes Waves

As He Did 1950,” Air Force Times (Nov. 5,

1984).

50. Quotes are from Memo for Secre -

taries of the Military Departments, Chairman

JCS, ASD/HA, IG, Director, Washington

Headquarters Services from Secretary of

Defense Casper Weinberger, January 20,

1984, subj: Review of U.S. European

Command Medical Readiness Planning,

Appendix A: Secretary of Defense Tasking,

to RADM James A. Zimble, MC USN,

Medical Readiness Planning in the U.S.

European Command (Department of

Defense: Medical Readiness Review Group,

Apr. 18, 1984), USUHS library. A note on the

cover of the document personally inscribed

by the author describes it as a “pre classified

version.” Admiral Zimble appears to have

sent it to Admiral Long. An Army doctor had

accused the Deputy USEUCOM surgeon, an

Air Force brigadier general, of directing the

aircraft commander of the aeromedical evacuation aircraft to land casualties from

Lebanon at a base where they could be admitted to an Air Force medical facility. “Medical

Readiness for War Stalled , Mayer Says,”

Army Times (Sept. 30, 1985): 1. Greendyke

papers.

51. Weinberger Memo.

52. William “Bud” Mayer, Charge to the

Review Group, Feb. 6, 1984, Appendix B,

Zimble Report.

53. Interview with Maj. Gen. (Ret.) Davis

C. Rohr, USAF, Sept. 30, 1997. Rohr was the

USEUCOM Director of Plans (J–5) at the

time. He referred to it long after the event as

“that terrible report” and indicated that the

370

Notes
USEUCOM staff directors felt that its conclusions had been determined in advance. 

54. Ron Richards made the same point

about the methodology of the review group

in his recent interview. The report notes that

what it termed “critical shortages” in deployable medical systems were identified first in

1976–1978 by a JCS-sponsored study of the

medical capabilities required to support a

conventional conflict between NATO and the

Warsaw Pact. Zimble Report, p. v.

55. Zimble Report, pp. 6, 8–9. The report

noted that JCS publications on the subject of

the USEUCOM surgeon’s authority, missions, and functions are ambiguous on the

first point and insufficiently delineated on the

second and third. Zimble Report, p. 18.

56. Zimble Report, p. 2. 

57. Richards interview.

58. Zimble Report, p. vi. OASD/HA did

not see aeromedical evacuation capabilities

as a major problem because evacuating casualties by air was no good unless there were

medical facilities to which they could be

taken for treatment. Richards interview.

59. Zimble Report, pp. 25–26. MAC was

responsible for both strategic aeromedical

evacuation and the worldwide evacuation

system utilizing C–9s domestically and in the

theaters. One telling criticism of USEUCOM

priorities was implied in the review group’s

report that, of six available C–9As in the theater, three had been configured for administrative missions, and there were no evident

plans for rapidly reconfiguring these aircraft

for aeromedical evacuation in contingencies.

60. Zimble Report, p. 26.

61. Zimble Report, pp. 27–28.

62. When interviewed long after the

events in question, Lawson spoke critically

about the lack of medical readiness he found

in the command when he became Deputy

Commander-in-Chief, Europe (DCINC -

EUR). Immediately preceding this assignment, Lawson had spent three years in senior

NATO positions, first as U.S. representative

to the NATO Military Committee, which provided military advice to the North Atlantic

Council, NATO’s governing political body,

and then, as chief of staff to the Supreme

Allied Commander, Europe (SACEUR).

Medical questions had begun to be a subject

for consideration by SACEUR headquarters

around 1980 when new positions were created on the Supreme headquarters’ logistic

staff, but, because aeromedical evacuation

and medical support of the national forces

committed to NATO were as a matter of

alliance policy each nation’s responsibility,

Lawson had no reason to be knowledgeable

except in the most general way prior to his

assignment as DCINC in Aug. 1983, several

months before the Lebanon bombing.

Referring to his SAC experience with

General Curtis LeMay, Lawson expressed his

belief that no prospective enemy would be

deterred unless you had a completely credible

defense posture including provisions to support your troops medically. Interview with

General Richard Lawson, July 29, 1997.

General John Chain, USAF, Lawson’s successor as SACEUR chief of staff wrote long

after his service that he had never dealt with

any issue pertaining to aeromedical evacuation during his tenure. Ltr to the author, June

17, 1997.

63. Interview with Col. (Ret.) Carroll

Bloomquist, MSC, SAF, Aug. 15, 1997.

Colonel Bloomquist served on the USEUCOM surgeon’s staff, 1981–1984, and later at

SHAPE for three years as the second medical

logistics staff officer.

64. Long after the events in question,

General Myers said that the impetus for his

initiative was the result of Dr. Beary’s testimony before Congress. According to Myers,

discussions were even held with the

Egyptians although it is not clear whether

actual contingency hospitals were established

there. Given Egypt’s later cooperation with

the U.S. Central Command, it seems probable. Myers interview. 

65. Myers Interview. Nocton Hall was a

former RAF hospital that was accepted by

371

Notes
the USAF in 1983 for the contingency hospital program. When activated, Nocton Hall

was staffed by medical personnel drawn from

the David Grant Medical Center at Travis

AFB. Operation Desert Storm After Action

Report, 310th USAF Contingency Hospital,

RAF Nocton Hall, United Kingdom, Mar. 15,

1991, p. 1. HQ USAFE/SGR, Target USAFE

Contingency Hospital Bed Availability by

CY, Dec. 17, 1985. Greendyke papers.

66. The Air Force chief of staff from 1974

to 1978 was General David Jones who as

USAFE commander immediately prior to his

selection had sought to put his command and

NATO air forces on a more positive war footing. One of his initiatives was the move of

USAFE headquarters from Wiesbaden on the

east bank of the Rhine River near Frankfort

to Ramstein, some sixty miles to the southwest and perhaps more importantly, some

fifty miles west of the Rhine River, the only

really formidable barrier to a Warsaw Pact

invasion in central Germany. In 1978, Jones

became chairman of the JCS where he continued to push for NATO readiness, a subject

of such importance to the Carter administration that it created the post of an undersecretary of defense to deal specifically with

NATO. Myers’ tenure as AF SG was from

1978 to 1982.

67. Morgan, Congressional Hearing

Resu me, p. 2. The actual estimates were classified, but some sense of what might have

been expected can be extrapolated from

General Rogers’ quarterly update of Sept.

1985 for the Secretary of Defense that “we

can very rapidly count on 65,000 beds in support of U.S. casualties...this will meet our

requirement for the first 30 days.” Resume

and statement copy in Greendyke papers.

68. Bloomquist interview. Interestingly,

whereas Dr. Mayer had testified about efforts

to speed the conclusion of more such agreements, he reportedly expressed great skepticism in private to CINCEUR and his staff

that the nations concerned would honor them

in actual crisis. USEUCOM Analysis of

Testimony of Dr. Mayer. Greendyke interview.

69. U.S. troops and airmen were in place

or scheduled to reinforce every continental

part of Allied Command, Europe, with the

U.S. Marines planning to enter Norway in

support of Norwegian forces. Personal

knowledge of the author.

70. Col. Craig Llewellyn, MC USA;

Captain John A. Hansen, MC USN; Col.

James G. Vermillion, MSC USA; Lt. Col.

Ronald A. Kerchner, USAF; Lt. Col.

Nicholas R. Hurst, USA; and Lt. Col. Herbert

M. Hamako, USAF MSC, “Wartime

Strategic/Domestic Aeromedical Evacuation

and Distribution of Patients,” Research

Report, ICAF, Apr. 1982, USUHS library.

71. “Wartime Strategic/Domestic

Aeromedical Evacuation and Distribution of

Patients,” pp. 22–23.

72. The Secretary of Defense had directed establishment of the CMCHS in 1980.

“Wartime Strategic/Domestic Aeromedical

Evacuation and Distribution of Patients,” p. 6

(footnote).

73. Interview with Dr. Craig Llewellyn,

July 31, 1997. Dr. Llewellyn was one of the

principal authors of the study. The president

of NDU at the time was Lt. Gen. John Pustay.

In a telephone call long after the event, he

recalled going to HA to successfully plead

the ICAF students’ case, but he could not recollect with whom he spoke. Interview with

Lt. Gen. (Ret.) Pustay, Aug. 3, 1997.

According to Dr. Llewellyn, the study was

briefed in Europe to various officials including the USAF Surgeon.

74. Lawson interview. Interview with

Col. (Ret.) John C. Patchin USAF MSC,

October 8, 1997.

75. “Talking Paper [TP] on The Air

Evacuation System–Will it Work?” USEUCOM SG’s office, n.d. Greendyke papers.

The paper’s answer was “yes,” and it

affirmed alliance policy that each nation

should provide its own airlift support while

showing procedures that would permit tap372

Notes
ping into all the various sources of airlift support throughout Europe. The AF expected to

incur its highest level of casualties during the

first five days of an attack when the Soviet air

offensive would strike USAFE main operating bases in an attempt to secure air superiority. Thereafter, USAF casualties were expected to decline while U.S. Army casualties

rapidly increased. The use of the AF contingency hospitals would then shift to receiving

Army casualties.

76. Colonel Patchin recalls that, when

projected evacuation requirements were presented to MAC representatives in the theater,

they indicated that there was no way they

could be met given operational airlift requirements. “Talking Paper [TP] on The Air

Evacuation System.”

77. Patchin interview.

78. The principal briefer recalled long

after the event that Admiral Smalls, CINCUSNAVEUR, began the briefing session by

telling the briefer to go ahead, but that he

would not believe anything that the briefer

said. Patchin interview.

79. Greendyke interview. Col.

Borngasser, HQ USAFE/SGAX, “Update

Talking Paper on Dedicated In-Theater

Aeromedical Evacuation,” Sept. 24, 1985.

Borngasser identifies Chong, the senior

MAC staff member, having “reluctance” to

support USEUCOM’s proposal. Greendyke

papers.

80. Quote from Ltr, Lawson to Ryan,

May 8, 1985. Copy in the Greendyke papers.

Greendyke interview.

81. Ibid.

82. Ltr Ryan to Lawson, June 4, 1985.

Greendyke papers. Herman Jones and

Patricia Warner, “History of the 375

Aeromedical Airlift Wing (MAC), Scott

AFB, Illinois, 1 January–31 December 1985,

Vol. I: Narrative,” p. 29, n.d. 375 AAW/HO,

Scott AFB.

83. 375 AAW 1985 History, pp. 47–48.

84. This was Maj. Gen. William H.

Greendyke, who had previously served as

both USAFE and USEUCOM command surgeon. Patchin interview. Telephone conversation with Gen. Greendyke Oct. 8, 1997.

Before he could move from Ramstein to

Patch Barracks, Vaihingen, Germany, where

USEUCOM headquarters was located, he

was relieved by Secretary of Defense

Weinberger. It was widely believed that this

was done at the behest of the ASD/HA.

Patchin, Johns, Lawson, and Mazzuchi interviews. Ron Richards indicated that this

appearance was deceptive and that the initiative had come from Weinberger, who had

become angry at what he perceived were

comments by Gen. Greendyke intended to

stimulate protests to Congress over new programs for military dependents’ care being

proposed by the OASD. Richards interview.

85. Col. Thomas J. Hughes, Chief, Pro -

fes sional Services, Officer of the Surgeon,

MAC, Staff Summary Sheet, subj: Wartime

Aeromed Capability & Aeromedical Evacu -

ation-Europe,” Sept. 9, 1985. Air Mobility

Command History Office.

86. Army medevac helicopters had

reportedly sought to land casualties from

fighting on Grenada on-board a Navy hospital ship and had been refused because the

crews had not been certified for such an operation. McKeown, Congressional Hearing

Resume. Medical planning for Urgent Fury

also appeared to be inadequate, and, according to the flight surgeon who accompanied

the first load of casualties moved to Barbados

by a C–130, they were in poor condition:

wounds wrapped in whatever was at hand

(including dirty clothing) and some individuals in need of expert medical care. URGENT

FURY: The United States Air Force and the

Grenada Operation (Scott AFB, IL: MAC

Office of History, n.d.), pp. 86–87.

87. These figures represented increases

from 14,739 patients and attendants and 796

missions. Ssgt Mary D. Hebert and Patricia

K. Warner, “History of the 375th

Aeromedical Airlift Wing (MAC), Scott

AFB, Illinois, 1 July–31 December 1989.

373

Notes
Vol. I: Narrative,” p. 8. AMC HO, Scott AFB,

n.d.

88. Patchin interview.

Chapter Eight

1. Ten–year evaluations of how effective

the Goldwater–Nichols legislation was in

fostering true “jointness” tend to be very positive, for example, William Bresson, draft

study, “Goldwater–Nichols: A Ten Year

Assessment,” (Cambridge, MA: Harvard

University Program on Information

Resources Policy, 1997). The results of the

Gulf War and various nonanalytic published

sources such as Colin Powell’s memoirs

seem to support this view. The author can

offer an anecdote from his own experience

that illustrates the Joint Staff’s apparent sense

of its position vis-à-vis the service staffs in

the early 1980s. A member of the Joint Staff

defended his joint staff agency to an audience

composed predominantly of representatives

from the unified overseas commands at the

Armed Forces Staff College in 1983 with a

revealing statement. The occasion was a conference to consider improvements in the Joint

Operation Planning System (JOPS, now

JOPES, “execution” having now been added

to its function). Pressed by many attendees to

include a particular improvement in the next

version of JOPS, the Joint Staff briefer

demurred, saying “You have to remember,

we’re only one of four,” indicating they could

not direct but only seek a consensus for such

a change. The author attended as a consultant

conducting a study of JCS Exercise Nifty

Nugget.

2. Interview with Admiral Long, Oct. 27,

1997. In fairness, the lack of communication

seems to have existed in both directions. One

USEUCOM staff officer recalls hearing an

obviously frustrated CINC prior to the terrorist attack tell the Deputy J3, a U.S. marine

brigadier general, in no uncertain terms to

find out what was going on in Beirut. In fact,

a USEUCOM liaison team was visiting

Beirut and was billeted quite near the Marine

barracks when the explosion occurred.

Telephone interview with Capt. (Ret.)

William Dial, USN MSC, January 13, 1998.

The personality of the individual CINCs

obviously played a role in their relations with

their formally subordinate but equal in four

star rank Service component commanders

whose materiel support came from their parent services. Following the disastrous terrorist attack, Gen. Rogers and his staff insisted

in changes in the physical protection of the

remaining marine force, according to Dial.

Long had himself been commander of a unified command, the Pacific Command, prior

to his retirement.

3. Colin Powell discusses the changes in

his memoirs: Colin Powell with Joseph E.

Persico, My American Journey (New York:

Random House, 1995), pp. 409–11. A particularly useful mechanism for enhancing the

CINCs’ authority was the greater control of

the budgets of their service components’ that

the CINCs were given by GNA. Interes -

tingly, the position given the chairman by the

GNA statute is not unlike the informal role

assumed by Gen. Maxwell Taylor as CJCS

vis-à-vis the Secretary of Defense and the

Joint Chiefs of Staff during the Kennedy

administration when the decision to intervene

in Vietnam was made. The legal position of

the members of the JCS was, of course, quite

different, as were the service cultures of the

time and the determination of Secretary of

Defense McNamara and the other civilian

officials of the administration to preclude

JCS involvement in decision-making. For

General Taylor’s situation, see the heavily

documented study by H. R. McMaster,

Dereliction of Duty: Lyndon Johnson, Robert

McNamara, the Joint Chiefs of Staff, and the

Lies that Led to Vietnam (New York: Harper

Collins Publishers, 1997).

4. Powell, My American Journey, p. 292.

Contemporary analyses were even more

harsh in some respects, and the official joint

history monograph echoes the same short374

Notes
comings in more measured and detailed

terms. See the assessment in Ronald H. Cole,

Operation URGENT FURY. Grenada

(Washington, D.C.: Joint History Office,

Office of the Chairman of the Joint Chiefs of

Staff, 1977), pp. 63–67. Gen. Norman

Schwarzkopf’s memoirs illustrate vividly the

interservice suspicion attendant to the

Grenada operation. Norman H. Schwarzkopf

with Peter Petrie, The Autobiography: It

Doesn’t Take a Hero (New York: Linda Gray

Bantam Books, 1992), pp. 247–55.

5. This was apparently another result of

the absence of medical planners from the

operational planning for Urgent Fury.

Complicating the situation was the similar

exclusion of the communication planners.

Capt. James L. Quinlan, USAF NC, “Tactical

Aeromedical Evaluation Grenada: Training

Made the Difference,” USAF Medical

Service Digest (Spring 1984): 2–3.

6. Telephone interview with Lt. Gen.

(Ret.) Frank G. Ledford, Jr., MC, USA, Nov.

12, 1997.

7. Perhaps the best account of the reasons

for the decision to remove Noriega and dismantle the PDF from the point of view of a

key high-level U.S. participant is Colin

Powell’s My American Journey, pp. 413–44.

8. The evolution and termination of MAC

command of Special Forces aviation is

chronicled in Anything, Anywhere, Anytime,

pp. 185–89.

9. In an interview several years after his

retirement as Air Force surgeon general, Lt.

Gen. Alexander Sloan described discussions

about augmenting aeromedical evacuation

aircrews regularly with physicians as having

gone on for “twenty years.” Telephone interview, Feb. 17, 1998. Regarding the changing

service attitudes toward joint operations, the

comment of one 82d Airborne Division

sergeant major is perhaps indicative of how

past problems in joint operations tended to

force greater cooperation. He commented

with regard to the paradrop on Torrijos airport

during Just Cause that “no one wanted to

repeat the f--ing snafu we had at Port Salinas

[Grenada].” In that flawed but ultimately successful operation, information had not been

provided to the Rangers–in part due to the

exclusion of intelligence from the operational

planning–that the Cuban construction workers building the new airport on Grenada were

Cuban reservists who carried their arms and

could be expected to resist vigorously. This

they did, including firing upon the U.S. paratroopers in the air. The unexpectedly heavy

resistance forced the Rangers to lower the

planned jump altitude, as would happen later

in Panama. Quotation is from Malcolm

McConnell, Just Cause: The Real Story of

America’s High-Tech Invasion of Panama

(New York: St. Martin’s Press, 1991), p. 294,

fn 3. For a full account of the Port Salinas

drop, see Cole, Operation URGENT FURY,

pp. 42–43. Telephone interview, Col. (Ret.)

Craig Llewellyn, USA MC, Feb. 5, 1998. Air

Force News Service, “Grenada: Special

Report,” Airman (Feb. 1984): 37. Norman

Schwarzkopf, who was initially detailed as

the Army observer to the staff of the joint task

force commander for the Grenada operation,

also describes Cuban resistance and its discounting in the planning for the operation

when he was told that the six to eight hundred

armed Cubans were “not going to fight.”

Schwarzkopf, It Doesn’t Take a Hero, pp. 247.

10. The indictment of Noriega for drug

trafficking in Feb. 1988 by a federal grand

jury was followed by a JCS planning order to

CINCSOUTH to write a contingency plan to

defend the Panama Canal and U.S. lives and

property in Panama. McConnell, JUST

CAUSE, p. 29. Cole, Operation JUST

CAUSE, also cites “nearly two years of deliberate planning” (p. 72). Col. Darrel Porr,

described by General Ledford, the former

army surgeon general, as the chief planner for

the operation, stated in a recent interview that

the medical planning had started two years

before. Ledford stated that his office had not

been involved with the medical planning.

Telephone interviews with Lt Gen. Frank

375

Notes
Ledford, USA MC, and Col. Porr, USA MC,

Nov. 12, 1997. Colonel Robert Brannon,

USAF MSC, who commanded the 1st

AMES, states in his unit’s after-action report

that planning was conducted over “several

months,” and he stated in a later interview

that he was brought into the planning in April

1984. The differences probably reflect the

changes in planning concept that were ongoing during 1984 and that intensified after the

decision to seize Noriega was made and

General Maxwell Thurman replaced General

Fred Woerner as CINCSOUTH in October

1989. Lt. Col. Brannon, “1st Aeromedical

Evacuation Squadron After Action Report,

Operation JUST CAUSE.” AMC Historical

Office, Scott AFB, IL. Telephone interview

Brannon, Feb. 16, 1998.

11. Immediately prior to the invasion,

Brannon deployed to Howard AFB in the

Canal Zone with elements of his squadron

where he helped establish the medical facilities for preparing U.S. casualties for evacuation. Brannon says that he also deployed to

Panama in May 1989 when Noriega cancelled the already completed elections for the

Panamanian presidency and U.S. action was

apparently at least considered. Brannon, Just

Cause after-action report. Telephone interview with Colonel Brannon, Nov. 12, 1997.

12. According to Brannon, the cover story

for his absence from Pope was that he had

“gone to Modesto,” and, when his immediate

superior in the medical chain of command,

the 375th Aeromedical Airlift Wing surgeon,

at Scott AFB tried to contact him for some

reason and was told that he had left for

California, the surgeon was both surprised

and irritated. Brannon also indicated that the

MAC vice commander might also not have

been informed of the “execute” decision.

Brannon telephone interview, Feb. 16, 1998.

Interview with VADM (Ret.) James Zimble,

former Navy surgeon general, Feb. 6, 1998;

telephone interviews with Lt. Gens. Frank

Ledford, USA MC, and Monte Miller, USAF

MC, on Feb. 9, 1998, and Feb. 11, 1998,

respectively. The apparent analogue to the

secrecy surrounding the invasion of Grenada

should not be pushed too far because it was

planned on a relatively hasty basis compared

to the two-year lead time on Just Cause for

most planning.

13. Telephone interview with Gen. Oaks,

Nov. 14, 1997. Oaks was still bemused eight

years after the event and repeated the

“bizarre” characterization of the instructions

he had received several times during the

interview. He related that he was informed of

the impending operation and information

restriction by two sergeants who introduced

themselves by one pulling a telephone from

his briefcase and telling Oaks to dial a certain

number to verify his visitors’ credentials. 

14. The same two emissaries who had

briefed Gen. Oaks also briefed Brig. Gen.

Vernon Chong, commander of Wilford Hall,

on the impending operation with the same

injunction to maintain secrecy. Telephone

interview, Col. (Ret.) Carroll Bloomquist,

USAF MSC. Bloomquist was the JMMC

Operations Officer at the time. The 18th

Airborne Corps curgeon had received a similar very late notification of Operation Urgent

Fury and injunction not to tell any of his staff

of the impending operation, an injunction

that he reportedly “bent” somewhat so his

medics would be better prepared to provide

the medical support necessary. Interview, Dr.

Robert Joy, Mar. 2, 1998.

15. Brannon, Just Cause after-action

report.

16. Some small increase in flight time

was occasioned by the need not to compromise the operation by flying the evacuation

missions over the Yucatan peninsula or other

parts of Central America. Consequently,

flight plans called for detouring east out over

the Caribbean Sea before turning on a direct

course for San Antonio. Interview Col.

Courtney Scott, Feb. 26, 1998. A map of the

area shows a direct course from Panama City

to San Antonio crosses Yucatan and parts of

Honduras and Nicaragua.

376

Notes
17. Telephone interview with Dr. Spencer

Greendyke, Sept. 30, 1997. At the time of

Just Cause, Greendyke, whose father had

been the first USEUCOM surgeon, was on

active duty as a doctor in the USAF temporarily assigned to Brooke. The ostensible

reason for designating Wilford Hall is supported by a variety of sources who confirm

the sensitivity of special forces’ commanders

to the exposure of their troops’ identities to

the public. Telephone interview with Col.

Brannon, Nov. 15, 1997; telephone interview,

Col. Bloomquist, Feb. 23, 1998; telephone

interview, Dr. Craig Llewellyn, Feb. 5, 1998.

Dr. Llewellyn is a former special forces surgeon who now directs the Military and

Emergency Medicine Division of USUHS.

In his interview, Gen. Oaks noted that there

was a “burble,” as he put it, the night of the

invasion: a telephone call from a very senior

military figure in Washington expressing

concern that the identities of the first loads of

casualties who were predominantly from the

special forces not be divulged to the press.

Oaks interview.

18. Brannon later said that consideration

had been given to deploying a full air-transportable hospital to Howard, but it was decided that this would require such a large effort

as to be too obvious that something was afoot

to PDF watchers. Brannon telephone interview, Feb. 16, 1998.

19. Brannon, Just Cause after-action

report. An Army Health Services command

spokesman reported that two physicians had

been sent from Fort Ord, California, and two

others from the Eisenhower Medical Center

at Fort Gordon, Georgia, all four of whom

had been alerted for the deployment prior to

the invasion. “Panama Operation: Readiness

Pays Off,” U.S. Medicine (Feb. 1990): 1, 7.

Colonel Porr, the 82d Airborne Division surgeon, jumped into Torrijos–Tocumen and

moved to Howard to assist in triage and treatment of the casualties. Porr telephone interview, Feb. 19, 1998.

20. Eight years after the event, this was

still the position of the Air Force surgeon

general in office during Operation Just

Cause, who expressed strong reservations

about moving stabilized rather than stable

patients. Telephone interview Lt. Gen. (Ret.)

Monte Miller, USAF MC, Feb. 12, 1998.

Although laudatory of the smoothness of the

working relationship between Army and Air

Force and the medical support of the operation’s casualties in a contemporary interview,

Miller was noted as having said that in general [my emphasis], the principles of triage

and air evacuation were complied with.

“Panama Operation: Readiness Pays Off,”

U.S. Medicine, p.7. One should note that definitions of “stable” and “stabilized” may differ among individual physicians, and the distinction between these conditions may be

more ambiguous than nonmedical observers

may believe.

21. Brannon, Just Cause after-action

report; Porr telephone interviews, Nov. 12,

1997, Feb. 19, 1998; Miller telephone interview, Feb. 12, 1998. In a 1993 article, three

USAF MC doctors, including the present

Director of the Air Force Medical Operating

Agency in the Office of the Surgeon General,

wrote that the medical support plan had

called for the patients to be stabilized in a surgical intensive care unit at Howard and evacuated to Kelly by air only when completely

stable. The authors attributed the actual evacuation of “stabilized” and not stable patients

to a failure of transportation for the 44th

Medical Brigade from Fort Bragg, which

ostensibly precluded postoperative recovery

and surgical intensive care at Howard. Earl

W. Mabry, Robert A. Munson, and Londe A.

Richardson, “The Wartime Need for

Aeromedical Evacuation Physicians: The

U.S. Air Force Experience During Operation

Desert Storm,” Aviation, Space, and

Environmental Medicine (Oct. 1993): 943.

However, two of the planners and participants who were at Howard state that this is

erroneous information. Telephone interview,

Col. Courtney Scott, USAF MC, Feb. 18,

377

Notes
1998, citing Col. Brannon; Porr telephone

interview, Feb. 19, 1998. It appears that the

JTFSO commander’s assertion that “early

joint planning, coordination, and rehearsal

enabled the medical operation to be executed

as planned,” was in fact correct, although

moving unstable patients did result in expressions of concern after the event, according to

Col. Porr in the interview just cited.

Quotation is from Memo for CINC, SOUTH,

from Lt. Gen. Carl W. Stiner, USA, Jan. 29,

1990, “First Impressions Report, Joint Task

Force South (JTFSO) ‘Operation JUST

CAUSE’ 20 Dec 89–12 Jan 90,” AMC

Historical Office.

22. The 624 Army Rangers who were

dropped at Rio Hato suffered a 35 percent

injury rate as determined by individual interviews of 471 troopers conducted by three

Army Medical Corps doctors within one

week of their return to Fort Bragg. This contrasts sharply with the 8.5 percent casualty

rate actually reported by the 44th Medical

Brigade for this unit. Ninety percent of the

Rangers injuries occurred during the jump,

an unsurprising conclusion given the low altitude and the fact that some must have landed

on the runway. Lt. Col. William F. Miser,

Maj. (P) Wade Lillegard, and Maj. William

C. Doukas, “Injuries and Illnesses Incurred

by an Army Ranger Unit during Operation

Just Cause,” Military Medicine 160 (Aug.

1995): 373. For analyses of the injuries and

wounds suffered by the casualties, also see

Capt. Theodore W. Parson; Majs. William C.

Lauerman, David B. Ethier, James E. Cain,

and Zev Elias; Lt. Col. Jeffrey; and Col.

William Gormley, all USAF MC, “Spine

Injuries in Combat Troops–Panama, 1989,”

Military Medicine 157 (Oct. 1957); and Dr.

Elliot Jacob, Maj. Joseph M. Erpelding, and

Capt. Kevin P. Murphy, USAF MC, “A

Retrospective Analysis of Open Fractures

Sustained by U.S. Military Personnel during

Operation Just Cause,” Military Medicine

158 (July 1983). The assault force was fired

upon from the ground at both Rio Hato and

Torrijos–Tocumen, according to the 82d

Division surgeon who parachuted into

Torrijos–Tocumen and then joined the medical team at Howard. Porr telephone interview, Feb. 19, 1998.

23. Jacob, et al., “A Retrospective Analysis

of Open Fractures,” pp. 554–55; Mabry, et al.,

“Wartime Need for Aeromedical Evacuation

Physicians,” p. 943. Three civilian physicians

also analyzed the disposition of the Beirut

casualties and concluded that the operation

emphasizes “the significant influence of early

and aggressive resuscitation on prevention of

such complications as sepsis [infection] and

multiple organ failure that lead to late death.”

Eric R. Frykberg, Joseph J. Teppas III, and

Raymond Alexander, “ The 1983 Beirut

Airport Terrorist Bombing: Injuries, Patterns

and Implications for Disaster Management,”

The American Surgeon 55 (Jan. 1989): 140.

24. Mabry and his coauthors assert that

each evacuation flight to Kelly “ultimately”

had a surgeon on board. However, Brannon

and others indicate that augmenting medical

personnel were carried only on the first two

aeromedical evacuation missions. Mabry, et

al., “The Wartime Need for Aeromedical

Evacuation Physicians,” p. 943. Porr telephone interview, Feb. 19, 1998; Brannon

telephone interview, Feb. 16, 1998. Brannon

in this interview noted that the SEAL leadership had asked that SEALs who were wounded in action or killed in action be evacuated

together if at all possible because this was

their general practice. Ironically in view of

the fact that the Just Cause evacuation

process served as an inadvertent model for

physician-augmented aeromedical evacuation crews, the flight surgeon on the second

evacuation flight was actually being expelled

from Howard because his presence was

unauthorized. Interview with Lt. Col. Farley

Howell, USAF NC, Feb. 26, 1998. 

25. According to a physician not involved

in the actual treatment of the casualties but

who conducted extensive research about the

effect on patients’ conditions of the way they

378

Notes
were evacuated, the entire staff of BAMC

was called in and kept on duty for the first

twenty-four hours. Interview Col. Courtney

Scott, USAF MC, Feb. 26, 1998. 

26. Taylor, Point Paper. The C–21, a small

administrative jet built by Learjet, can be

configured variably for no litters and seven

seats (for ambulatory), one litter and five

seats, or two litters and three seats.

Operational support aircraft [OSA] became

MAC’s responsibility in 1988.

27. Spencer Greendyke interview;

Brannon, Just Cause after-action report. Gen.

Oaks recalls escorting the President and his

party through the hospitals to meet the casualties. Oaks interview. Cole, Operation JUST

CAUSE, p.65. The evacuee who died after

reaching Kelly was a Navy SEAL who the

triage personnel at Howard decided could not

survive if he were retained at the air base but

might if he could be gotten to Wilford Hall or

Brooke. Porr telephone interview, Feb. 12,

1998; Brannon telephone interview, Feb. 16,

1998. The army surgeon general expressed

his general approbation of the medical support provided the evacuees, noting only one

exception: he believed that one evacuee’s leg

amputation might have been precluded if

there had been a vascular surgeon on the

ground at Howard. Ledford telephone interview, Nov. 12, 1997. Brannon afterward stated that his decision to send KIAs on the first

two aircraft was in response to a prior request

by a senior Navy SEAL officer to evacuate

SEAL WIAs and KIAs together, if at all possible, because this was their normal procedure. Twenty-eight C–9 and three C–21

domestic aeromedical evacuation missions

moved 215 of the evacuees from Kelly to

other locations in CONUS. Lt. Col. John

Brower, MAC DOOX, Point Paper, subj:

Operation JUST CAUSE, Apr. 12, 1990.

AMC Historical Office.

28. Brannon, Just Cause after-action

report. Brannon telephone interview, Feb. 16,

1998. The fact that airlift was available to

deploy these reservists so quickly seems to

cast further doubt on the asserted “transportation” failure explanation for the absence of

purportedly planned additional 44th Medical

Brigade personnel to provide intensive postoperative care and to ensure that evacuees

were clinically stable. It should be noted that

special forces deploy only limited medical

capability and doctrinally look to the early

evacuation of their casualties.

29. Looking back on his thirty-seven-year

career, the former Air Force surgeon general,

Lt. Gen. Alexander Sloan, characterized regulating as a frequent source of tension

between the services that was marked many

times with an ongoing suspicion of the Air

Force because it controlled the evacuation

vehicles. Telephone interview Feb. 16, 1998.

See Chapter 6 for what would seem to be a

persuasive case study of the truth of Sloan’s

observation during the early years of the

Vietnam War. The modern medical regulating system dates from World War II, which

also saw the conflict between the air surgeon

and the surgeon general of the Army over the

U.S. Army medical department policy of not

differentiating AAF aircrew from ground

force casualties in returning them to duty.

30. When the joint directive was issued,

six Army commanders had the authority to

regulate patients in their respective areas

without reference to ASMRO, and the commanders of ten naval districts also had the

same authority in their districts. Lecture,

“Medical Regulating,” Wing Base Surgeon’s

Course, Gunter AFB, [Alabama], Aug. 17,

1954, USAF Office of the Surgeon General,

Health & Education Division (File: Record

Group 341, Entry 44, box 138, NARA II). An

audit of the system some twenty-five years

later seems to show that, if anything, the situation was worse. Memo for the ASD/HA

and the Asst. Sec. Air Force (FM) from

James H. Curry, Defense Audit Service, subj:

Draft Report on the Audit of the Worldwide

Aeromedical Evacuation System (Project

8ST-033), Nov. 6, 1978, p. 39. AMC/HO. 

31. “Overview of the Armed Services

379

Notes
Medical Regulating Office,” n.d., AMC

Historical Office. Office of the MAC

Surgeon, “Briefing Regarding Establishment

of Air Force Medical Regulating Concept,”

June 5, 1968. Office of the Surgeon General

Historical Files. 

32. For example, the Hoover commissions of the late 1940s and early 1950s. See

Chapter 4.

33. Draft audit report, Worldwide

Aeromedical Evacuation System, 1978.

Nowhere in the report does there appear any

sense that there may be legitimate sizing

issues for the domestic AE fleet of C–9s and

supporting AE squadrons pertaining to

wartime contingencies, especially a possible

NATO–Warsaw Pact War.

34. “Medical Regulating” Lecture. Local

base populations or dependents and retirees

living near AF hospitals were not likely to

generate patients of clinic interest on a continuing basis sufficient to support specialty

and residency programs for new AF physicians. Memo, Harry R. Rowell, Chief

Medical Evacuation Branch, ASMRO, for

Historian, OSG, USAF, Mar. 4, 1952. RG

341, Entry 44, box 138. Although less valid

than during World War II when the Army

ground and service forces ran the Army hospital system overseas and handled AAF casualties inappropriately fro m the air surgeon’s

point of view, the same concern that only Air

Force flight surgeons understood the peculiar

medical requirements of aircrew must have

been an element in the Air Force’s attitude

toward wanting to treat its own members.

35. Memo, Col. Anthony H. Vervena for

375 Aeromedical Airlift Wing CC/CV/

Surgeon, subj: ASMRO Relocation, 25 Sep

81 Meeting Report, Sept. 28, 1981. 375th

AAW Wing Archives, Scott AFB, IL. Vervena

notes that the Army is opposed to the move,

but that the ASD/HA had initiated the project,

culminating a series of overtures over the preceding fifteen years to effect this collocation.

36. According to Col. Brannon, who was

constantly involved with special forces as

commander of the 1st AES, their commanders always preferred to evacuate any casualties they might have suffered to the Womack

Hospital at Fort Bragg where access to them

could be tightly controlled. Brannon telephone interview, Feb. 16, 1998. This sensitivity was confirmed by Col. Scott. Interview,

Feb. 24, 1998.

37. T. E. Kowalsky, J. Griffen, and 1/Lt G.

M. Cusack, Aeromedical Airlift Model (Scott

AFB, Ill.: HQS MAC, Command Operations

Analysis, Nov. 1968). CORONA HARVEST

Documents, HRA, Maxwell AFB, Ala.

38. Draft Audit Report on the Worldwide

AE System, 1978, 42–43.

39. Telephone interview, Col. Carroll

Bloomquist, Feb. 23, 1998.

40. Frank Best and Nancy Tomich,

Medicine in the Gulf War (Washington, D.C.:

U.S. Medicine, Inc., 1995), pp. 130–31.

41. Best and Tomich, Medicine in the

Gulf War. Perhaps anticipating the aggressive

nature of public interest from his experiences

with Just Cause, Gen. Oaks, the USAFE

commander, directed during Desert Shield

that facilities be provided near the various

contingency hospitals in Europe for family

members who might choose to travel to be

near wounded and sick relatives. Oaks interview. Stiner after-action report.

42. Scott interview. Col. Scott had been a

resident in public health in San Antonio and

conducted extensive interviews with the participants in the evacuation and care of the

casualties and reviewed the bulk of patient

records in his research. Scott’s analysis and

conclusions are contained in “The Impact of

Strategic Aeromedical Evacuation in

Operation JUST CAUSE,” June 1991, which

was never formally published reportedly

because it was felt that it might occasion criticism of the Air Force. According to Scott,

only eight copies were ever made and distributed. Scott interview Feb. 24, 1998. 

43. Col. Jones, MAC/SGRO, Point Paper,

subj: MAC Aeromedical Evacuation Support

for URGENT FURY, 24 October to Present

380

Notes
(for MAC Medical Facility Commanders and

Administrators Conference, 14–16 Decem -

ber 1983), Nov. 28, 1983. AMC Historical

Office. MAC Office of History, Urgent Fury:

The USAF and the Grenada Operation, pp.

86–87. Flight surgeons augmentees were

added to the standard medical crews as a precaution since the absence of communications

between the combat zone and Barbados

where an AECC had been established made it

impossible to obtain information on how stable casualties needing evacuation were. 

44. Looking back in 1998 on the early

years of TRANSCOM, CINCTRANSCOM,

Gen. Walter Kross, who from May 1990 until

July 1991 had been General Johnson’s

Director of Operations and Logistics (J3/4),

noted that prior to the Gulf War, the

TRANSCOM components and their parent

Services were very “suspicious” of their new

superior joint headquarters, “particularly at the

highest levels of leadership.” They viewed

TRANSCOM as a “threat” to the way they

had been doing business, but when he returned

as the CINC, the situation had changed radically because the Gulf war had demonstrated

the need for TRANSCOM to act as a “single

entity.” General Walter Kross, An Oral History

(Scott AFB, IL: TRANSCOM Research

Center, October 1999), pp. 1–2.

45. Anything, Anywhere, Anytime, p. 175.

The study concluded that the then current

mobility forces could meet the requirements

of any of the contingencies postulated.

46. Anything, Anywhere, Anytime, pp.

175–78.

47. Point Paper, Subj: Status of Aero -

medical Evacuation (AE) Conversion Kits for

CRAF Airlift, Aug. 23, 1985, attached to Staff

Summary Sheet (SSS), Subj.: Aeromedical

Evacuation–Europe (CSD #3505), Aug. 23,

1985, signed by Brig. Gen. Vernon Chong,

MAC Surgeon. AMC History Office.

48. SSS Subj: Aeromedical Evacuation–

Europe, Aug. 23, 1985.

49. Point Paper, Status of Aeromedical

Evacuation (AE) Conversion Kits for CRAF

Airlift, Aug. 23, 1985. Msg., Vernon Chong,

MAC Surgeon, to JCS/J–4, Subj: Patient

Distribution Study and CONUS Beds, Aug.

22, 1985. AMC Historical Office. 

50. See the CINC’s annotation for Gen.

Chong, the MAC Surgeon, on Point Paper,

Subj: Status of Aeromedical Evacuation (AE)

Conversion Kits for CRAF Airlift, Aug. 23,

1985. The CINC wrote in the margins that he

thought there was “a natural reluctance

among OJCS/OSD to belly up to hard numbers [for the number of wartime casualties

and CONUS beds available] because they

believe those numbers will be used to justify

high cost airlift/medical programs,” and he

emphasized getting a “good handle on a low

cost [emphasis in the original], universal

CRAF conversion kit.”

51. The DoD plan for the CRAF was presented to air carrier industry executives in

March 1952. MATS had proposed that all

331 required four-engine CRAF aircraft be

modified to accommodate litter equipment

and that four-engine transport aircraft manufactured in the future should have litter

assemblies installed on the production line.

Maj. Gen. Robert M. Lee, USAF Director of

Plans, for the Surgeon General, subj: The

Civil Reserve Air Fleet Plan, Apr. 24, 1952.

(File: K237.163-3, 52/03/20-55/04/00,

HRA.) Draft CONOPS, attached to memo

from Col. Mahlon H. Long, to HQ AMC [Air

Mobility Command, successor designation

of MAC], Subj: Civil Reserve Air Fleet

(CRAF) Aeromedical Evacuation Shipset

System (AESS) Operational Status Report,

Nov. 9, 1994. AMC History Office.

52. SSS, Subj: CRAF Aeromedical

Evacuation Memo of Agreement Between

MAC and Aerospace Medical Division

(AMD), Aug. 22, 1986, signed by Brig. Gen.

Paul E. Landers, USAF, Asst. Deputy Chief

of Staff, Plans, Hqs., USAF.

53. SSS, Subj: Aeromedical Evacuation

Memo of Agreement. Draft AE Civil Reserve

Air Fleet (CRAF) CONOPS. AMC History

Office.

381

Notes
54. The double- and single-litter stanchions composed the patient transport system

(PTS); the therapeutic oxygen composed the

medical oxygen subsystem (MOS), and the

two nurse work stations together with the

electrical distribution system composed the

aeronautical operations subsystem (AOS).

Point Paper, Subj: Civil Reserve Air Fleet –

Aeromedical Evacuation Ship Set (CRAFAESS), Aug. 1996. Draft AE Civil Reserve

Air Fleet (CRAF) CONOPS. AMC History

Office.

55. SSS with proposed Ltr, CINCMAC to

the Air Force Surgeon General, Subj: CRAF

Aeromedical Segment Incentives, May 25,

1988, signed by Maj. Gen. Richard

Trzskoma, DCS/Plans. AMC History Office.

Chapter Nine

1. CENTCOM was not the only organization that was evaluating an Iraqi-initiated conflict in the Middle East in late July 1990. One

of the scenarios being “played” at the annual

Global War Game conducted by the Naval

War College in Newport, Rhode Island, during July was an Iraqi invasion of Kuwait. This

“move” in the game occurred virtually simultaneously with the actual invasion on August

1, 1990. The author was a participant in the

Global War Game at the time.

2. Aeromedical Evacuation in the 1990s:

The United States Plan and a NATO

Proposal, n.d. I am indebted to Col. (Ret.)

Carroll Bloomquist, USAF MSC (who was

assigned to the SHAPE staff at the time) for

a copy of this proposal. With this proposal,

the United States thus for the first time in the

area of medical support formally breached

“the wall” between those functions deemed

“national responsibilities” (such as logistical

support of each nation’s own forces) and

those functions that the NATO nations as a

group had agreed should be performed-and

funded-jointly to support the forces they had

committed to NATO’s continental military

arm, Allied Command, Europe (ACE). The

NATO aeromedical force would have been

funded under the NATO infrastructure program on the obvious model of the NATO airborne warning and control system (AWACS).

The NATO AWACS were Boeing E–3A aircraft manned by airmen from several NATO

nations that provided early warning of a

Warsaw Pact air attack on ACE. See Arnold

Lee Tessmer, Politics of Compromise: NATO

and AWACS (Washington, D.C.: National

Defense University Press, 1988).

3. Naturally enough, returning many of

those U.S. forces stationed in Europe that had

been committed to NATO’s integrated military structure assumed a high priority. Many

of these units were scheduled to be disbanded after they arrived in the ZI. This drawdown of U.S. forces was to be accomplished

within the context of agreements for a mutual reduction of forces in Europe by both

NATO and the Warsaw Pact. Ironically in

view of what was to happen a year later, the

senior U.S. Army commander in Europe in

the spring of 1989 sought to justify retaining

the U.S. Seventh Corps largely intact in

Europe as an alliance-sanctioned “out of

area” rapid-response force, although the

alliance at that time still refused to use forces

committed to it for anything other than the

direct defense of NATO territory. The author

was present in Heidelberg, Germany, in May

1989 when his director of operations, an

Army major general, argued this position

vigorously for visitors from the National

Defense University in Washington.

4. In 1986, the Air Force, Army, and Navy

lost control of planning, programming, and

resource allocation for their medical facilities

to a “Defense Medical Facilities Office,” and

on October 1, 1991, these functions were

made subject to the authority of the Assistant

Secretary of Defense for Health Affairs.

Joseph Marchese, Regionalization in the Air

Force Medical Service World War II Through

1993 (Washington, D.C.: Office of the

United States Air Force Surgeon General,

[n.d.]), pp. 12–13.

382

Notes
5. As noted in the last chapter, General

Ledford, the army surgeon general during

both Just Cause and the Gulf crisis identified

his fear at the time that the Panama evacuation

might be seen by Congress as a model for the

future that would allow reducing appropriations for the U.S. Army medical department.

Telephone interview, Dec. 11, 1997.

6. One knowledgeable retired MSC officer stated that the UTC designations were at

least partially inspired by bureaucratic considerations and represented an Air Force

attempt to demonstrate an enhanced “readiness” role for flight surgeons in response to

the heavy emphasis placed on readiness by

the influential William Mayer while

ASD/HA during the Reagan presidency.

Telephone interview, Col. (Ret.) Carroll

Bloomquist, USAF MSC, Sept. 20, 1998.

Bloomquist was assigned to ASD/HA at the

time after assignments on the USEUCOM

and SHAPE staffs. Mayer had served as

Governor Reagan’s California state education chief’. 

7. Telephone interview, Lt. Gen. (Ret.)

Alexander Sloan, USAF MC, Feb. 17, 1998.

8. The most authoritative although necessarily condensed description of the role that

aeromedical evacuation played in the Gulf

conflict is in Dr. James Nanney, “Medical

Support,” vol. III: Logistics and Support, pt.

II, pp. 201–31, and Thomas Keaney, Eliot

Cohen, et al., The Gulf War Air Power Survey

[GWAPS] (Washington, DC: Government

Printing Office, 1994). Envisioned by the

Secretary of the Air Force as a counterpart to

the U.S. Strategic Bombing Survey of World

War II, the authors interviewed key participants and had full access to pertinent classified documents. The quasi-official product is

the departure point for all further research.

Frank Best and Nancy Tomich, Medicine in

the Gulf War (Washington, DC: U.S.

Medicine, Inc., 1995), provide a comprehensive account of medical support based largely on interviews. Although unofficial, it was

produced with the active encouragement of

high DoD officials and the services’

Surgeons General. The positive accomplishments of the medical services are stressed in

Engelborg Sore, ed., Perspectives on the Gulf

War (1993), a compilation of some ninetyone short articles by participants, and originally published in special issues of The

Journal of the Army Medical Department

during 1992. Throughout this chapter, the

term MAC will be used to also denote

TRANS.

9. With the advent of the 7th Corps, the

numbers of U.S. forces committed went from

approximately two hundred thousand to

more than five hundred thousand.

International Institute for Strategic Studies,

Strategic Survey: 1990–1991 (London:

Brassey’s for the IISS, May 1991), p. 65.

Some Army MTFs were probably not fully

capable in the opinion of Col. Robert

Ferguson, USAF MSC, the CENTCOM

medical planner. Interview, Ferguson by Dr.

James Nanney, Nov. 25, 1991, pp. 42–43.

10. The concept of the “golden

hour”–although not necessarily precisely an

hour–is prevalent in surgical circles and

based on casualty analyses from previous

wars in which U.S. forces were engaged.

Although statistics on patient mortality or

survival from the Vietnam conflict can be

misleading, the ability of “dust off” helicopters to medevac casualties quickly to the

many fixed hospitals throughout the country

was an implicit validation of the “golden

hour” concept. There are similar inductively

derived periods of significance with respect

to when burn patients can be moved and

when microbes found in wounds take firm

hold of casualties in the form of full-blown

infections.

11. The term “patient movement” denotes

transport of one patient between two points.

Hence, the number of patient movements

theoretically may well be greater than the

number of actual casualties. Given the structure of the AE system in the AOR, that is, a

series of C–130 “hubs” from which casual383

Notes
ties were transported in one flight to fixed

medical treatment facilities in the rear of the

combat zone, the number of patient movements should largely equate to the number of

casualties. This should also be true of patient

movements in the strategic aeromedical

evacuation from the AOR to Europe because

the approximately eight-hour flight was well

within the C–141’s unrefueled range.

Casualty figures are from Lt. Col. Robert

Brannon’s “After Action Report/Operation

DESERT SHIELD/STORM,” AMC H/O.

Brannon commanded the 1611th AMES during Desert Shield/Desert Storm, which

included all elements assigned to the AE system. Eight years after the event, Edwin

Tenoso, General Horner’s Commander,

Airlift Forces (COMALF), who assumed his

position in mid-October, 1990, recalled being

given a figure of ten thousand casualties per

day for the first few days of combat to use in

planning his AE requirements. This figure

appears to be one calculated for the larger

forces programmed after the November decision and does not necessarily disagree with

the casualties estimates in Brannon’s afteraction report because Brannon cites average

patient movement requirements per day as of

December 15, 1990, for an unspecified period, presumably the duration of ground combat. According to Col. Robert Ferguson, who

was CENTCOM medical planner, he

received several revised casualty figures for

planning, all of which were in his opinion

absurdly high. In his opinion, the JCS medical planning module that was being used to

calculate estimated casualties was inaccurate

because its parameters were those associated

with a NATO–Warsaw Pact combat in

Europe. Telephone interview, Lt. Gen. (Ret.)

Edwin Tenoso, USAF, Jan. 29, 1999.

Interview, Col. Ferguson, USAF MSC, Jan.

7, 1999. Col. Richard Devereaux, USAF, a

C–5 airlift pilot serving in the JCS J–3

Readiness Division, recalled in a recent interview having also heard (and been skeptical

of) the estimate of ten thousand casualties per

day. In his position as Horner’s COMALF

responsible for the AE system, Tenoso had to

take such an estimate seriously for planning,

whatever he may have thought of its realism.

12. Gen. Schwarzkopf describes the Iraqi

defenses along the Kuwait–Saudi border in

graphic detail. It Doesn’t Take a Hero, p. 37.

13. In accordance with the total force concept, CENTCOM had included reserve formations in pre-crisis planning for possible

operations in its AOR. Frank N. Schubert and

Theresa L. Kraus, gen. eds., The Whirlwind

War (Washington, D.C.: Center of Military

History, U.S. Army, 1995), p. 57. In many

cases, these reserve units had unique functional capabilities no longer found in the

active force, which made their mobilization

absolutely essential.

14. Currently, Title 10 United States Code

(U.S.C) 12301d provides for the callup of

reservists who volunteer for active duty for

periods of time governed by funds availability and other conditions. Title 10 U.S.C.

12304, “Presidential Selected Reserve CallUp Authority” (PSRC), provides for the call

to active duty of up to two hundred thousand

members of the selected reserve when the

President determines that it is necessary to

augment the active forces for any operational

mission. Neither of these actions requires a

presidential proclamation of a national emergency. At the time of the Gulf crisis, these

authorities were contained in different sections of Title 10, which was revised in 1986.

United States General Accounting Office

(GAO), Reserve Forces: Proposals to Expand

Call-up Authorities Should Include

Numerical Limitations (Washington, D.C.:

GAO/NSIAD-97-129, Apr., 1997), pp.

12–14. For a detailed study, see Lt. Col.

James E. Lightfoot, ANG, Mobilizing the Air

National Guard for the Persian Gulf War:

Lessons and New Directions (Maxwell AFB,

AL: Air University Press, Nov. 1994). An

earlier useful perspective is Michael

Killworth, The Silent Call-up Option:

Volunteerism in the Air National Guard

384

Notes
(Maxwell AFB, AL: Air University Press,

1992).

15. Interview, Maj. Virginia Schneider,

ANG NC, Jan. 26, 1999. Maj. Schneider was

chief of the Medical Readiness & Training

Division of the ANG air surgeon’s office at

the time of this interview. Nanney, “Medical

Support,” GWAPS, p. 201. 

16. Nanney, “Medical Support,” GWAPS,

p. 200. The 1st Tactical Hospital deployed

from Langley AFB, Virginia, and was operational with an initial fourteen-bed capability

on August 15. A second, which had been

prepositioned in the AOR, became operational with a similar initial bed capability on

August 19. Lt. Col. Robert Ferguson, USAF

MSC, “Operations Desert Shield and Storm:

Air Force Medical Plans and Operations,”

unpublished paper, Nov. 25, 1991, p. 12.

Colonel Ferguson was the CENTAF medical

planner at Riyadh during the Gulf crisis. His

paper was presented to the annual meeting of

the American Military Surgeons of the United

States on that date. I am indebted to Dr. James

Nanney, historian, Office of the Surgeon

General, USAF, for a copy of this paper.

17. The decision not to use these “roundout” reserve brigades appears to have been

sound. According to the GAO, “Army

National Guard combat brigades had significant training-related readiness problems.”

Consequently, after being mobilized, the

Guard brigade devoted its training to achieving many fundamental skills for the first time

rather than honing individual and collective

skills that the members of the active duty

brigades that were substituted already had.

GAO, Military Training: Lessons Learned

and Their Implications for the Future

(Washington, D.C.: GAO/T-NSIAD-94-128,

Mar. 10, 1994), p. 8. In a book written seven

years after the Gulf war, the former Assistant

Secretary of Defense for Reserve Affairs

ignored the GAO’s findings and attributed

the decision not to deploy the roundout

brigades to bias by the active duty Army

leadership. See Stephen M. Duncan, Citizen

Warriors: America’s National Guard and

Reserve Forces & the Politics of National

Security (Washington: Presidio Press, 1997).

Curiously, Duncan neither mentions the

extensive mobilization of Air Force units for

the Gulf crisis nor their contributions to

CENTCOM’s success, particularly in the

major areas of airlift or aeromedical evacuation. Gen. Schwarzkopf discusses the controversy in his memoir and notes that the issue

was resolved by sending one of the NG

roundout brigades to the National Training

Center where it was still not ready after sixty

days of intensive training. It Doesn’t Take a

Hero, pp. 322–23.

18. The only active duty tactical AE

squadron was the 1st based at Pope AFB,

North Carolina. Three other active duty AE

squadrons provided medical crews for the

C–9s that conducted intratheater aeromedical

evacuation within the European and Pacific

commands and the domestic aeromedical

evacuation system. These were the 2d based

at Rhein-Main Air base, the 9th at Yokota Air

base, Japan, and the 57th at Scott AFB. All

these units and the associated flying

squadrons were elements of the worldwide

aeromedical evacuation system directed by

MAC. A recent history of the Air Force

Reserve notes the heavy involvement of

AFRES medical personnel in Desert Shield/

Desert Storm, but dismisses the subject with

the comment that all AFRES medical units

were called to active duty without saying anything at all about the major contribution made

by AFRES aeromedical evacuation units.

Gerald T. Cantwell, Citizen Airmen: A History

of the Air Force Reserve, 1946–1994

(Washington, D.C.: Air Force History and

Museums Program, 1997), p. 366.

19. Telephone interview, Lt. Col. (Ret.)

Philip Mahlum, USAF MSC, Feb. 9, 1999.

Colonel Mahlum was assigned to Medical

Plans (SGX) in the Command Surgeon’s

office at MAC/AMC, 1982–86 and 1990–94,

and at the time of this interview was a consultant to TRANSCOM.

385

Notes
20. Lt. Col. Paul McGuire, USAF NC,

ANG Liaison to the AMC surgeon, who was

Maj. Schneider’s predecessor in the ANG air

surgeon’s office, indicated that almost all of

the ANG’s aeromedical evacuation personnel

served voluntarily in the AOR on a rotating

basis for periods averaging forty-five days

during Desert Shield prior to the mobilization

of their ANG units. Telelphone interview,

Nov. 25, 1998.

21. For a description of the then existing

statutory authorities within Title 10, U.S.

Code, see Killworth, The Silent Call-up

Option. Those called up from the ARC were

mobilized ultimately for 179 days, as 180

days was the maximum under the provisions

of Title 10 at that time.

22. Maj. Dale Roberts, USAF MSC,

Aeromedical Evacuation Planner’s Guide

(Scott AFB, IL: Office of the Command

Surgeon, n.d.), p. 3. The Planner’s Guide,

issued as an unofficial publication, covers

every aspect of aeromedical evacuation in

detail and was widely distributed within the

active and ARC AE communities. It is still

considered an invaluable reference. Tele -

phone interviews, Lt. Col. Kerrick Jan. 28,

1999; Feb. 9, 1999; Col. Bloomquist, Jan. 25,

1999. Mahlum interview, Feb. 9, 1999. Air

Force medical UTCs begin with the alpha

characters “FF.”

23. Requests for additional personnel from

Colonel Brannon were screened carefully at

both the joint staff level and at AMC with an

eye toward keeping the numbers of U.S.

troops in Saudi Arabia. Mahlum interview,

Feb. 9, 1999. In his memoir, Schwarz kopf

reveals his sensitivity to King Fahd’s undoubted concern at the reaction in his kingdom to

allowing large numbers of foreigners into

Saudi Arabia. It Doesn’t Take a Hero, p. 305.

24. McGuire interview, Feb. 25, 1999;

telephone interview, Col. James Fischelli,

USAFR MSC, Feb. 9, 1999. For the dates of

activation and deployment locations of all

ANG and AFRES units mobilized during

Desert Shield/Desert Storm, see GWAPS, Vol.

5: A Statistical Compendium and Chronology

(Washington, D.C.: Center for Air Force

History, 1993), pp. 97–115. The activation

dates listed for AE units must be viewed with

some caution because the data does not seem

to differentiate between voluntary activations

and involuntary call-up by UTC. However,

mobilization dates for AE units in December

1990 are undoubtedly accurate because the

expansion of CENTCOM’s medical support

was set in motion at that time. As noted, volunteers still in the AOR were recalled to their

ARC aeromedical evacuation units, which

were then mobilized and ordered to duty in

the AOR. Schneider interview, Jan. 26, 1999;

interviews, McGuire, Feb. 23, 1999;

Fischelli, Feb. 9, 1999. Fischelli, now

Director of Health Affairs at AFRES HQ,

was Senior Air Reserve Technician (ART)

and commander of the 37th AE Group at

MacDill AFB, Florida, one of two AFRES

tactical AE Groups. Another complicating

factor was that some AE personnel in some

ARC units had already been mobilized by

UTC and were in the AOR when the decision

was made to activate their units.

25. For discussions of the PSRC, see

Lightfoot, Mobilizing the Air National

Guard, pp. 26–30, and Killworth, The Silent

Call-up, pp. 13–18. Killworth quotes the then

relevant subparagraph in its entirety. Sub -

para graph 672(d) of 10 U.S.C. 672, which

dated from 1952, specified that “at any time”

the secretary of the service concerned was

empowered to “order a member of a reserve

component under his jurisdiction to active

duty, or retain him on active duty, with the

consent of the member.” Originally, this

power was qualified by the need to obtain the

consent of the governor of the parent state of

the Guard unit, but this was removed from

the law in 1986.

26. Lightfoot, Mobilizing the Air National

Guard, p. 34.

27. For example, the satellite photographs

of Baghdad that the Air Force F–117s needed

for their precision attacks on selected targets

386

Notes
were not available until October. Michael R.

Gordon and Lt. Gen. (Ret.) Bernard E.

Trainor, The Generals’ War: The Inside Story

of the Gulf War (New York: Little, Brown

and Company, 1995), p. 99.

28. Interview, Col. Robert H. Brannon,

USAF MC, by Dr. James Nanney, HQ,

USAF/SGI, June 26, 1992.

29. Interview, Lt. Gen. (Ret.) Alexander

Sloan, USAF MC, Aug. 20, 1997; telephone

interview with Col (Ret.) Robert Brannon,

USAF MSC, Feb. 16, 1998. Best and

Tomich, Medicine in the Gulf War, p. 98.

30. Widely varying sources attest to the

fear that existed that the Iraqis would employ

chemical weapons. Colonel Brannon in his

interview eighteen months after the war

remarked that the threat of chemicals “really

terrified people” and that the amount of fear

was “remarkable.” Nanney interview, June

26, 1992. The operations group commander

of the ANG’s 136 Tactical Airlift Wing

whose C–130s were based at Al Ain in the

United Arab Emirates made the same unsolicited observation in an interview many

years after his service there. Discussing the

TAES system in the AOR, the Air Guards -

man volunteered that especially in conversations with the COMALF regarding AE techniques to use in transporting chemical casualties, he got the impression that there was

extreme concern about the possible use of

chemicals. Interview, Lt. Col. Ronald Hale,

ANG, Jan. 11, 1999. The COMALF, Brig.

Gen. Edwin Tenoso, also recently confirmed

his concern about the possible impact on the

AE system of casualties from Iraq’s use of

chemical warfare. Telephone interview, Lt.

Gen. (Ret.) Edwin Tenoso, USAF, Jan. 29,

1999.

31. The then Col. Robert Belihar, the

CENTCOM surgeon, noted in an interview

shortly after the war that “we relied a great

deal more on tactical air evac, C–130, than

we thought we would, because we moved so

fast [and] I think we have to reevaluate that

aspect of it, as far as evacuation from the forward areas.” Best and Tomich, Medicine in

the Gulf War, p. 67. In a paper delivered at a

USUHS conference on military medicine,

Belihar was more explicit, saying flatly, “The

evacuation distances...were too great for

Army and U.S. Marine Corps helicopters.”

Quoted in “Desert Storm: CENTCOM

Overview,” Apr. 13, 1992, p. 136, from the

multivolume transcript of the 7th Conference

on Military Medicine “The Spectrum of

Medical Support for Operation Desert Shield

and Desert Storm,” held at USUHS, Apr.

13–15, 1992. Hereinafter cited as 7th

Conference on Military Medicine.

32. Sloan interview, Aug. 20, 1997.

33. Schubert and Kraus, The Whirlwind

War, p. 86.

34. Best and Tomich, Medicine in the

Gulf War, p. 98. Nanney, “Medical Support,”

GWAPS, p. 28. Tel. interview, Col. Gerald

Andrick, USAF MSC. Col. Andrick, who

was on the AFRES crisis action team during

the Gulf conflict, cites along with many other

sources Congressman Murtha of

Pennsylvania as the instigator of this directive that responded to his injunction to avoid

having large additional CHAMPUS charges.

35. Brannon, after-action report, Apr. 17,

1991. Brannon notes that the initial staff of

the AECC was fifteen.

36. Mabry, Munson, and Richardson,

“The Wartime Need for Aeromedical

Evacuation Physicians,” p. 943. This article

is based in part on Dr. Mabry’s War College

thesis that was kindly provided to the author

by Dr. Lt. Col. Munson. Nanney interview,

Brannon, June 26, 1992. This action apparently was less linked to the Just Cause experience than the attempts by the Air Force’ to

ensure that all its medical personnel had

clearly identified wartime roles as demanded

by Dr. Mayer during his tenure as ASD/HA.

According to a retired MSC officer who was

assigned to the OASD/HA in the late 1980’s

during Dr. Mayer’s tenure, UTCs for flight

surgeons in aeromedical evacuation units had

been created prior to Operation Just Cause,

387

Notes
although the roles they were to perform in the

AE system had not been fully defined. Tel.

interview, Col. Carroll Bloomquist, USAF

MSC, Sept. 20, 1998.

37. The Mississippi ANG unit was

equipped with C–141s and the New York

ANG unit with C–5s. The ANG aeromedical

evacuation squadron as a subordinate unit of

the 186th Airlift Group at Meridian,

Mississippi, which was equipped with C–141

aircraft, came under the operational control

of MAC as a strategic aeromedical evacuation unit when activated in contingencies.

38. In the GWAPS chronological list of

Air Force Reserve units that were brought on

active duty for the Gulf crisis, the 72d is listed as “mobilized” on Aug. 8, 1990 which

erroneously implies a unit activation.

GWAPS, Statistical Compendium and

Chronology, p. 98. Actually, as indicated,

both AFRES strategic AE squadrons at

McGuire provided volunteers who deployed

to the Gulf on Aug. 10. The civilian-operated

L–1011 aircraft were used because the capability of the C–141s of the 438th Military

Airlift Wing at McGuire, like the rest of the

MAC airlift fleet, was being fully utilized to

move troops and their equipment to the AOR.

Tel. interview, Col. (Ret.) Carl Merwin,

USAFR MSC, Feb. 27, 1999. Col. Merwin

served in the dual capacity of commander

and senior air reserve technician (ART) for

the 69th and its successor, the 514th AES,

from 1971 until late 1998. He was also the

AE representative on the 21st Air Force’s crisis action team (CAT) during the bulk of the

Gulf crisis. The 21st AF, located at McGuire,

was the MAC unit that controlled the MAC

strategic airlift wings on the East Coast.

39. GWAPS, Vol. 3, Part I: Logistics, p. 87.

40. Merwin interview, Feb. 27, 1999.

41. Tel. interview, Col. Brannon, Feb. 2,

1999. Nanney interview, Brannon, June 26,

1992. Interview, Lt. Col. Loren Flossman,

ANG MSC, Dec. 8, 1998. Flossman commanded the 142d AES, ANG, stationed at

New Castle, Delaware. Flossman’s Delaware

unit was one of five ANG AE units to which

McGuire made the “what if” calls that prepared the ANG to respond affirmatively

when the message arrived from MAC shortly after Brannon’s call. Flossman recalled

receiving a personal telephone call from

Brannon on Aug. 4 to join him on the deployment as a volunteer. They had known each

other while Flossman had been on active

duty prior to going to the ANG and had later

worked together. Flossman volunteered and

directed the AECE at Rhein-Main Air Base

during Desert Shield, then served as

Brannon’s chief of staff at the AECC in

Riyadh during Desert Storm. Tel interview,

Flossman, Feb. 1, 1999.

42. Tel. interview, Lt. Col. Paul Mcguire,

USAFR NC, Jan. 29, 1999. McGuire

received Brannon’s secure telephone call. At

the time of the Gulf crisis, McGuire, now

ANG liaison to the Office of the AMC

Command Surgeon, was Chief, Aeromedical

Evacuation and Training, Office of the Air

Surgeon, ANG, and served as the officer in

charge of the medical/aeromedical cell in the

ANG contingency support staff (CSS) that

was activated for contingencies. As such, he

handled taskings from MAC, which was the

gaining command for mobilized ANG and

AFRES AE units. In his Jan. interview,

McGuire noted that, unbeknownst to him, the

ANG air surgeon had previously received a

“heads-up” call via a secure telephone that a

classified tasking message would be forthcoming from AMC.

43. Nanney interview, Brannon, June 26,

1992. Tel. interview, Col. Gerald Andrick,

USAFR MSC, Feb. 5, 1999; Fischelli interview, Feb. 9, 1999. Andrick was at AFRES

HQ during the Gulf crisis.

44. Quotation is from Nanney interview,

Brannon, June 26, 1992. In retrospect,

Brannon thought the ANG was asked to fulfill most of this initial requirement because it

had more volunteers than the AFRES did.

Tel. interview, Brannon, Feb. 2, 1999. 

45. For a detailed discussion of the ANG

388

Notes
response to the Gulf crisis under the then current provisions of Title 10, U.S. Code, see

Lightfoot, Mobilizing the Air National Guard

for the Persian Gulf War, pp. 22–27.

46. McGuire interview, Sept. 30 1998;

Andrick interview, Feb. 5, 1999.

47. Tel. interview, Lt. Col. (Ret.) Philip

Mahlum, USAF MSC, Feb. 4, 1999. Col.

Mahlum was a medical planner at HQ, MAC,

from Sept. 1990 through the end of the Gulf

War. Among other things, the lack of validated TPYDD prohibited use of the JCS automated planning system, the Joint Operations,

Planning and Execution System (JOPES),

and required manual deployment planning.

“Chronology”, GWAPS, Vol. 5, Part II, p. 13.

One of the CENTCOM planners told interviewers a year after the war that casualty estimates and requirements to handle them were

essentially done with “a stubby pencil...and

the seat of the pants” because the lack of

computer terminals both in CENTCOM

headquarters and at the component commands precluded the JCS medical planning

model from being used in the AOR.

According to him, some officials could not

move beyond the planning module because

“they were still thinking the deliberate planning process.” Tomich and Best, Medicine in

the Gulf War, p. 86.

48. Col. Kenneth G. Swan, “Heaton

Lecture – Combat Casualty Care,” Perspec -

tives on the Gulf War, p. 5. Swan offers an

insightful critique of the medical care available in the Gulf through comparison to the

Vietnam conflict. He notes that in the latter

one-third of the twenty-four in-country hospitals were evacuation hospitals that functioned as university hospitals or level 1 trauma centers because their staffs included all

surgical subspecialties. Swan characterized

them as providing “incredible, and probably

never again to be seen, efficiency in the delivery of lifesaving care to the combat casualty

of the Vietnam War while the US was there.”

49. Tel. interview, Brig. Gen. (Ret.)

Jerome Foust, USA MSC, Mar. 3, 1999.

Foust was commander of the 44th Medical

Brigade responsible for the medical support

of the 18th Corps units as they rapidly

advanced into Iraq through the desert west of

Kuwait. At the end of hostilities, his medical

units had penetrated 150 miles into Iraq, and

he had established hospitals on the Euphrates

River. The then Col. Robert Belihar, who had

served as the CENTCOM surgeon during the

Gulf crisis, also expressed concern about the

limited range of medevac helicopters to provide effective evacuation support of these

forces advancing directly into Iraq. Maj. Gen.

(Ret.) Robert Belihar, Oral History.

50. Interview, Maj. Gen. Earl W. Mabry,

USAF MC, Feb. 24, 1998. Gen. Mabry noted

in his interview that there were eight Army

five-hundred-bed hospitals within a twentyfive-mile radius of King Khalid Military

City, which was relatively close to the

Kuwaiti border. Mabry arrived in Riyadh in

early Jan. 1991 from assignment to the MAC

surgeon’s office.

51. Dhahran received roughly five times

more MAC strategic airlift sorties than did

any of the next three major APODs during

the period from Aug. 1990 to Feb. 1991.

GWAPS, Vol. 3, Part I: Logistics, pp. 142.

52. Maj. Stephen Wintermeyer, Joseph

Pina, Maj. James Cremins, and Capt. Jeffrey

Heier, “The Inpatient Experience of a U.S.

Army Combat Support Hospital in the

Persian Gulf during Non-Combat and

Combat Periods,” Military Medicine, 159

(Dec. 1994): 747.

53. Various factors affect helicopter range

and lifting capability. Range and speed estimates offered by different Army aviators who

flew support helicopters differed widely: for

Hueys from 170 to well over 200 nautical

miles; for Blackhawks, 250–300 nm. Hueys

cruised at 90–100 knots and Blackhawks at

130–150 knots. On internal tanks, each had a

flight duration of approximately two hours.

Tel. interviews, Maj. Deborah Snyder, USA,

Feb. 19, 1999; CW4 (Ret.) Edward Merfut,

USA, Feb. 25, 1999; CW3 Curtis Hoagland,

389

Notes
Mar. 3, 1999. Maj. Snyder flew helicopters

during Desert Shield/Desert Storm from

King Fahd International Airport and moved

to Log Base C at Raffa two miles from the

Iraqi border to support 18th Airborne Corps

units in their western attack. At the time of

the interview, Maj. Snyder was the S–3

(Operations Officer) of the 12th Aviation

Battalion stationed at Fort Belvoir, Va., which

was Mr. Marfut’s unit of assignment until

retirement. Mr. Hoagland is a member of the

District of Columbia Army National Guard

medevac unit. All interviewees noted that the

range of both helicopters could be increased

significantly with external or internal fuel

tanks. However, auxiliary fuel tanks degraded their medevac capability by limiting the

space available to carry either litters or ambulatory patients.

54. Lt. Col. Eldon Ideus, “Patient Evacu -

ation and Regulation: Tactical and Strategic,”

7th Conference on Military Medicine (Apr.

14, 1992): 16–18. Colonel Ideus pointed to

the range limitations of the UH–1s as the primary problem but also noted that surgical

patients tended to “queue” rapidly for evacuation and that a higher-capacity medevac

vehicle than either the Huey or the

Blackhawk was necessary. In fairness, it

should be noted that the deputy CENTCOM

surgeon, Ben Knisely, a former medevac

pilot himself, gently disputed that locating

FARPs was a problem in an telephone interview eight years after the event, although

Ideus, who commanded the medical group

supporting 18th Airborne Corps, characterized navigation for either ground or air evacuation vehicles as “difficult at best.” Knisely

interview, Mar. 25, 1999.

55. Best and Tomich, Medicine in the

Gulf War, pp. 83–84.

56. Even in Vietnam, the limited range of

the “Hueys” had initially posed a problem for

moving patients from emergency treatment

points to the Army’s Eighth Field Hospitals at

Nha Trang. Col. O’Neill Barret, “U.S.

Medicine in Vietnam: The Early Years,” in

Brig. Gen. Andre Ognibene, and Col. O’Neill

Barrett, Jr., (eds.), Medical Department,

United States Army: Internal Medicine in

Vietnam. Vol. II: General Medicine and

Infectious Diseases (Washington, D.C.:

Office of the Surgeon General and Center of

Military History, 1982), pp. 26–27. As noted

earlier, the CENTCOM surgeon, Col.

Belihar, remarked about the unexpectedly

greater use of tactical airlift for patient evacuation. Medicine in the Gulf War, p. 57. 

57. The quotation is from the transcript of

a discussion following a breakout session on

“Medical Support to TO&E Units,” 7th

Conference on Military Medicine (Apr. 14,

1992): 131.

58. For example, in the same forum, Gen.

Walter Boomer expressed his dismay at the

lack of a sufficient number of helicopters to

ensure that marine casualties could be transported from ground units at the front to Navy

second-echelon MTFs. Capt. Jerry Crim,

USN MC, “Organic Marine Corps Medical

Support System,” pp. 248–9. Captain Crim

noted that medical evacuation was “a problem,” and that even with the dedication of

eight helicopters to medevac on the eve of

conflict, there was so much smoke, swirling

sand, and confusion at times during the

ground war, that the helicopters might have

been ineffective anyway in some locations,

pp. 246, 249. Col. Reginald Moore, USA

MC, who deployed with the 44th Medical

Brigad, and then was reassigned to “Task

Force Evac,” a provisional unit of the reserve

332d Medical Brigade assigned to medical

support of 7th Corps, indicated that medical

evacuation was one of the greatest worries of

the task force’. In spite of vigorous planning

on how patients could be medevaced out of

the 332d’s hospital by helicopter, “there were

seldom any helicopters available.” The solution was to use C–130s at two existing airfields near brigade hospitals and at two new

airfields constructed near its other evacuation

hospitals. “Active Duty Reserve and

National Guard Evac Hospital Group,”

390

Notes
“Fixed Hospital Units,” 7th Conference on

Military Medicine (Apr. 15, 1992): 10.

59. Commander Charles Hora, USN MC,

in Tomich and Best, Medicine in the Gulf

War, p. 86. The commander of the 44th

Medical Brigade which had set up its first

second-echelon treatment facility in the AOR

in early September 1990, also stated flatly

that the necessary medical support for operations was late in deploying. However, he

added that he reported to the 18th Airborne

Corps commander on the eve of the ground

war that the necessary medical facilities were

now in place. Tel. interview, Brig. Gen. (Ret.)

Jerome Foust, USA MSC, Mar. 3. 1999.

60. Edward J. Marolda and Robert J.

Schneller, Jr., Shield and Sword: The United

States Navy and the Persian Gulf War

(Washington, D.C.: Naval Historical Center,

1998), p. 106. Capt. David A. Snyder, USN

MC, “USNS COMFORT in Desert

Shield/Storm: Lessons Learned, Fixed

Hospital Units,” 7th Conference on Military

(Apr. 15, 1992): 30–31. Snyder, a staff surgeon on Comfort during the Gulf crisis,

points out that the advertised one-thousandbed capability may be more theoretical than

real in a combat environment because, statistically, 60 percent of combat-inflicted injuries

are orthopedic and the wards are at the bottom of the ship. Patients would have to traverse six stairwells, a difficult access for

patients who could not walk and a potential

disaster if abandoning ship became necessary. Another veteran of the deployment also

noted wryly the difficulty of providing nursing care to patients in the tiered bunks higher

than shoulder high. Interview, Capt. Dennis

Vidmar, USN MC, May 1, 1998.

61. Dr. Vidmar was Chief of Dermatology

at the National Naval Medical Center at the

time and was embarked on Comfort during

Desert Shield/Desert Storm. The vessels’

helicopter landing pads were capable of handling one Blackhawk or two smaller medevac helicopters at a time, thus limiting the

influx of litter patients from each landing to

perhaps a dozen. Interview, Capt. Dennis

Vidmar, USN MC, June 5, 1998. 

62. Tel. interview, Capt. Vidmar, Mar. 11,

1999. Capt. Charles Blankenship, USN MC,

“Utilization of Hospital Ships,” 7th Confe -

rence on Military Medicine, (Apr. 15, 1992):

114. Clearing the ships of patients to provide

room for fresher casualties would have been

virtually impossible. Capt. Blankenship estimated that it would have taken two and a half

days flying round the clock with no mechanical malfunctions to offload a full load of

patients.

63. Capt. Thakar Patal, USN MC, “Fleet

Hospital Five,” “Fixed Hospital Units,” 7th

Conference on Military Medicine (Apr. 15,

1992): 88. Marolda and Schneller state that

Fleet Hospital 15 was airlifted from a storage

site in Norway and set up at Awali, Bahrain.

However, they are contradicted flatly by Lt.

Commander Dana Covey USNR MC, who

was an orthopedist on that hospital’s staff and

told the audience twice at the USUHS conference on medicine in the Gulf War that the

hospital was in the desert, north and west of

al-Jubayl, noting that Fleet Hospital 15 “was

the one placed by General Boomer.” “Fleet

Hospital 15 in ODS,” pp. 44–46. In a

November staff meeting, Boomer had

opposed putting a fleet hospital in Bahrain on

the basis that “if the battle is in Kuwait, a fleet

hospital in Bahrain is too damn far.” Boomer

quotation is from Shield and Storm, p. 130.

According to Marolda and Schneller, a third

fleet hospital was deployed to Bahrain on the

orders of Admiral Arthur, NAVCENT commander.

64. Lt. Gen. Walter Boomer, Opening

remarks at 7th Conference on Military Med -

icine (Mar. 13, 1992): 23–25. Boomer said

that, although he had believed the medevac

system would work as it had from his point of

view in Vietnam, he had since come to the

realization that it would not “in a campaign in

which we have a large number of casualties.”

65. Commander Richard R. Jeffries,

“Medical Preparations, Accomplishments

391

Notes
and Concerns of the 1st Marine Division

from Operation Desert Shield/Storm,” 7th

Conference on Military Medicine (Apr. 14,

1992): 30. Jeffries reported that Fleet

Hospital Five requested help from the Army,

which provided eight Blackhawks for medevac, of which neither Jeffries nor the Marine

division to which he was attached were

aware at the time. One motivating factor for

the Army provision of medevac helicopters

to Fleet Hospital 5 may have been the fact

that, after the arrival of the first 7th Corps

troops, many of them were treated at Fleet 5,

according to its commander, Capt. Thaker

Patel. Reflecting the uncertainties experienced during preparations for Desert Storm,

Patel noted that the evacuation policy

reached almost thirty days in November, and

that his hospital functioned unofficially for

several months as a general hospital. “Fleet

Hospital 5,” p. 89. Capt. Terrence Riley, former Force Surgeon for the II Marine

Expeditionary Force (MEF) reported in a

1992 article that Marine helicopters had been

“dedicated” to medevac during the Gulf War

and that they had moved patients and casualties from front areas to second-echelon facilities and from the latter to the fleet hospitals.

They were actually reserved for medevac

because they did not carry the red cross

markings, putting them under the Geneva

Convention. In any event, they were too few

to handle the marine casualties as indicated

by what Navy medical officers at the fleet

hospitals reported also in 1992. “Medical

Services to the Marine Corps in Desert Shield

and Desert Storm,” Perspectives on the Gulf

War, p. 46. Capt. Riley’s generally positive

presentation does not correlate with Gen.

Boomer’s comments cited in the text.

66. Covey, “Fleet Hospital 15 in ODS,”

7th Conference on Military Medicine (Apr.

15, 1992): 44–46. Knisely interview, Mar. 25,

1999.

67. Covey, “Fleet Hospital 15 in ODS,”

p.48. The use of Air Force C–130s to evacuate second-echelon Marine MTFs was also

not without problems. In one instance,

patients were sent to the MASF with the

agreement that they would be evacuated

within six hours”,” but it took three tries that

involved two patients being operated on

again after one returned to the sending MTF

before the patients were evacuated. Capt.

Frederick Burkle, USN MC, “Battlefield

Casualties from Second Echelon Marine

Facilities, Mobile Hospital Units and

Detachments,” 7th Conference on Military

Medicine (Apr. 14, 1992): 62. Of course, one

other advantage C–130s had over helicopters

was the number of patients they could carry,

an important factor when the number of casualties expected was so high. 

68. Tel. interview, Capt. Vidmar, Mar. 12,

1999. Based on Comfort’s experience,

Vidmar was scornful of the “protection”

afforded the hospital ships by the Geneva

Convention in the Gulf. By contrast, he

pointed out that the British generated and

deployed to the Gulf a very capable hospital

ship, Argus, which they kept unmarked and

in battleship gray. 

69. Ibid. Tel. interview, W. Hays Parks,

Oct. 10, 1998. Dr. Parks serves in the

International Law Division of the Depart -

ment of the Army’s legal staff. He cautions

that the degree of protection afforded a hospital ship properly marked and operating

under Geneva Convention procedures and

protections is limited. A belligerent can seize

such a vessel and remove the combatants

aboard making them prisoners of war.

However, under the convention, he would

have to let the ship and the medical personnel

aboard proceed without restraint.

70. Other limiting factors affecting hospital ships in any contingency include the draft

of the vessels and the depth of the waters

within which they operated. In Desert Shield,

one vessel remained in the Gulf at all times,

while the other remained just outside. During

Desert Storm, both operated inside the Gulf.

Interview, Capt. Dennis Vidmar, USN MC,

May 1, 1998. Dr. Vidmar notes that the for392

Notes
ward position of USNS Comfort was

obscured a good part of the time by smoke

from the onshore oil installations that the

Iraqi forces had set alight. The ships formal

Geneva Convention status also precluded

having classified communications capability

on board, which presumably inhibited coordinating with Marine commanders.

71. Snyder, “USNS COMFORT in Desert

Shield and Desert Storm,” Apr. 14, 1992 p.

32. Capt. (Ret.) Taylor Cook, USN MC,

“Component Command Surgeons and

Planners – U.S. Naval Forces Central

Command Combat Medical Support, Fixed

Hospital Units,” 7th Conference on Military

Medicine (Apr. 15, 1992): 229; Burkle,

“Battlefield Casualties from Second Echelon

Marine Facilities,” pp. 63–64.

72. Brannon’s after-action report is a virtual roadmap for creating an aeromedical

evacuation system capable of supporting

another Gulf campaign. According to one of

his coauthors who served under Brannon during Desert Shield/Desert Storm, this was

done consciously on the assumption that the

Gulf conflict was the model of the kinds of

contingencies that the United States would

face in the future. Nine years after the event,

Brannon’s former subordinate expressed

some doubt about this assumption and the

thrust it had imparted to their recommendations. Interview, Lt. Col. Farley Howell,

USAF NC, Feb. 26, 1998. However, an

analysis of its recommendations including

adding UTCs to provide all the capabilities

needed for the tactical AE system to function

in areas like the Gulf AOR with its bare

bases, relatively thin communications infrastructure, limited road network, and difficult

climate certainly suggests that these recommendations have been relevant to those contingencies that the United States has faced

since the Gulf crisis.

73. Brannon after-action report, p. 3. The

ANG’s 142d AES based at New Castle, Del.,

provided the personnel for the Incirlik AELT,

and the 142d commander, Lt. Col. Flossman,

directed the AECE at Rhein-Main during

Desert Shield and served as Brannon’s chief

of sttaff during Desert Storm. Brannon notes

that this was the first time AECEs had been

deployed in a contingency. Flossman, a fellow MSC who had served on active duty with

Brannon, was also a personal friend and had

volunteered for active duty at Brannon’s specific request. Interview, Flossman, Dec. 8,

1998. McGuire interview, Feb. 34, 1999.

74. Brannon after-action report, p. 3. An

initial operational capability is defined as the

time at which a unit is capable of performing

at least one complete cycle of its assigned

mission.

75. Brannon after-action report, pp. 2–3.

76. The refusal was apparently based on

the fact that basing C–9s in the AOR would

have required deploying new and separate

maintenance and logistics capabilities to Gulf

bases that, in any event, were already overcrowded. Additionally, C–9 maintenance was

provided by civilian contractors whose availability might be questionable even if potential issues of liability were addressed in the

contract. However, beyond these concerns

was the fact that the readiness of the C–9 fleet

had declined after its funding was shifted

from the Airlift Service Industrial Fund

(ASIF) to the Air Force Medical Program

three years earlier, where it had to compete

for increasingly scarce funds. CINCMAC

laid out the problems with C–9 funding and

readiness directly to the Air Force chief of

staff in Sept. 1990 in a message described by

an SG staff member as “an attention getter!”

Msg. CINCMAC to CSAF, subj: Desert

Shield – Operational Impact on C–9A

Nightingale, Sept. 11, 1990. AMC Historical

Office Files. Removing the C–9s from

Germany would obviously have hampered

continuing the level of care for troops and

dependents left behind in Europe that

EUCOM was seeking to provide. The loss of

the C–9s would also eliminate one means for

“leveling” hospital populations among MTFs

in Europe if the casualty flow required it,

393

Notes
although the Germans had offered to help in

this regard. Tel. interview, Maj. Gen. James

Whinnery, ANG MC, Sept. 28, 1998.

General Whinnery was mobilized and served

at USAFE headquarters during the Gulf crisis working for General Roadman, the

USAFE surgeon. 

77. Brannon, after-action report, p. 3.

78. Brannon, after-action report, p. 1. The

formation of the 1611th was part of a general

reorganization of the various MAC units into

a structure of provisional tactical airlift

squadrons and supporting units. This was

done largely because of General Horner’s

concern about the difficulties of administering military justice with personnel when the

organizations retaining administrative and

disciplinary over them were scattered

throughout the United States. GWAPS, Vol. 3:

Intratheater Airlift, p. 148. 

79. The 5th MASH had to assume a similar general medical treatment role because

“there was no one else to do it.” Col. Kenneth

Steinweg, “Innovation in the Desert: MASH

Medical Packages for Desert Warfare,” 7th

Conference on Military Medicine (Apr. 14,

1992): 18. Col. Steinweg also noted that his

unit had to deal with “a lot of automobile

accidents,” in the King Khalid Military City

area during the period from December 1990

to January 1991 prior to moving forward to a

staging point for the “left hook” assault.

“Innovation in the Desert,” p. 17. Moore,

“Active Duty Reserve and National Guard

Evac Hospital Group,” p. 7.

80. During the early part of Desert Shield

as U.S. forces were still increasing slowly,

the Air Force had excess hospital capability

in the air transportable hospitals (ATHs) that

it had rapidly deployed to the AOR, and the

evacuation policy was briefly set at thirty

days. Interview, Colonel Leonard Randolph,

USAF MC, by Dr. James Nanney, Apr.

29–30, 1992.

81. Brannon, after-action report, 21–22.

There were patient movement requirements

from sixteen different locations. Attachment

5 to the report lists the five samaritan channels established. Earlier, opportune airlift for

aeromedical evacuation within the AOR had

sufficed with the smaller number of personnel in the AOR.

82. GWAPS, Vol. 3: Logistics, pp. 145–49.

83. The concept of coordination and collocation of joint medical assets at strategic

“hubs” is credited to Lt. Col. David Harper,

USAF MSC, by Col. Robert Ferguson, the

CENTAF surgeon’s medical planner in the

Gulf. Ferguson, “Operations Desert Shield

and Storm: Air Force Medical Plans and

Operations,” Nov. 25, 1991, p. 16.

84. Brannon, after-action report, Table 2,

p. 9, and Table 9, p. 22.

85. Brannon’s after-action report addresses the communications problems in some

detail (pp. 47–51). Maj. Gen. Randolph, the

CENTAF surgeon at the time made a special

point of identifying communications as his

principal problem both in the immediate period following the Gulf War and eight years

later in an interview with the author. Nanney

interview, Apr. 29–30, 1992; Randolph interview, Apr. 5, 1999. Frequent references to

communications problems can be found

throughout the relevant literature. For example, Lieutenant Gary Rebholz, “Medical

Logistics,” 7th Conference on Military

Medicine (Apr. 14, 1992): 96, 102–4.

Rebholz noted that it was easier to call Fort

Dietrick, Md., than it was to contact Fleet

Hospital 5, “just up the street.”

86. Tenoso interview, Jan. 29, 1999;

Brannon interviews, Mar. 7, 1998 and Feb.

10, 1999. Randolph interview, Apr. 5, 1999.

General Tenoso in turn was responsible to

General Horner, the Joint Force Air

Component Commander (JFACC), who

according to Tenoso gave him a totally free

hand to run the airlift forces and AE system.

87. The author’s interviews with each of

these officers indicate a continuing respect,

and even affection, existing among them.

Randolph was later to speak approvingly of

the idea that there was a “comraderie of field

394

Notes
experience” in discussing relationships

among the medics in the AOR. Support for

this conclusion is also implicit in their collective acceptance of the ad hoc “fixes” to which

they agreed and that crossed so many command lines and that, in many cases, transcended doctrine. Clearly, Brannon’s role

was key and viewed as such by his superior,

Tenoso, who refused to accept the assignment of several Air Force full colonels with

AE backgrounds to the 1611th unless they

agreed to serve under Brannon, who was

junior to them in rank. Those who agreed

were assigned to Tenoso directly and then

detailed to positions in the AE system under

Brannon’s command. Full colonels who

refused such an arrangement were rejected.

Tel. interview, Lt. Col. Farley Howell, USAF

NC, May 13, 1999; interviews, Merwin, Feb.

26, 1999; Fischelli, Feb. 9, 1999; and Lt. Col.

(Ret.) Philip Mahlum, USAF MSC, Mar. 21,

1999. 

88. Mahlum interviews, Feb. 9 and Mar.

21, 1999. The formal requests were in the

form of changes in the TPFFD, which after

approval by both CENTAF and CENTCOM

were sent to the JCS and then to MAC for

“sourcing,” that is, identifying where the

resources would come from by the MAC surgeon’s office. Frequent informal telephone

conversations between Brannon and the

MAC surgeon’s planners preceded the formal

requests.

89. Brannon, after-action report, pp. 8–9.

90. Ibid, p. 10.

91. See fn. 91. The commander of the

44th Medical Brigade had worked with

Brannon at Howard AFB during Operation

Just Cause and obviously admired the latter’s

role in the AE of casualties to San Antonio.

Foust interview, Mar. 3, 1999. Foust indicated that he had expected AE to be conducted

in the Gulf as it had been during the Panama

operation. A highly trained clinician also

rated as a flight surgeon who deployed to the

AOR with assignment to the AE system characterized Brannon as liked and trusted by all

elements of the CENTCOM medical support

system. Tel. interview, Col. Londe

Richardson, June 9, 1999. Others contacted

echoed these positive judgments.

92. Brannon, after-action report, pp.

9–10.

93. Like the distribution of personnel

from ARC units in groups rather than as integral units, the crosstraining reportedly created a certain degree of resentment.

94. Nanney interview, Col. Randolph,

Apr. 29–30, 1991. According to the concept

of operations, the Army was supposed to

have a MEDSOM functioning by sixty days

after forces deployed to the theater.

95. Foust interview, Mar. 3, 1999. The

medical planner on the JCS staff reported in

1992 that 61,000 requisitions for medical

supplies had been filled during the Gulf War

at a cost of more than $47 million. Capt.

Joseph Smyth, USN MC, “Medical

Readiness Role on [sic] Joint Staff,”

“Component Command Surgeons and

Planners,” 7th Conference on Military

Medicine (Apr. 13, 1992): 165.

96. ARC medical flight crews were generally told incorrectly that the necessary supplies were already in the AOR. According to

Brannon, the only aeromedical equipment

available for the first four months of Desert

Shield was that brought by the MASFs and

the crews from the 2d AES at Rhein-Main,

and two ARC units, the 69th and 72d AES

from McGuire AFB, which normally flew

strategic AE missions on C–141s.

Fortuitously, the reserve crews had assembled their equipment prior to receiving these

assurances and decided to bring it anyway.

Brannon, after-action report, pp. 7–8.

Interviews, Schneider, Jan. 26, 1999;

Fischelli, Feb. 9, 1999. Brannon is partially

contradicted by Fischelli who said that he

dispatched 112 volunteers to the AOR with

their equipment from the AFRES 37th

Medical Group, which he commanded during the first thirty days of Desert Shield.

97. Nanney interviews, Randolph, Apr.

395

Notes
29–30, 1999; Ferguson, Nov. 25, 1991.

98. Ibid. Lieutenant Rebholz, the Navy

MSC who worked at the MEDSOM noted

when discussing medical logistics the next

year that, as with the government of Japan

and NBC equipment and supplies, aeromedical evacuation equipment and supplies

required “special management” to coordinate

their receipt and distribution. Rebholz,

“Medical Logistics,” p. 96. The CENTCOM

surgeon office was apparently not always

enthusiastic about the approach of CENTAF

to obtaining medical supplies outside prescribed channels. Interview, Col. Robert

Ferguson, USAF MSC, Jan. 7, 1999.

Ferguson was the CENTAF medical planner

in the AOR. General Pagonis, who set up the

CENTCOM logistics system in the AOR,

makes no mention in his memoirs of any

problems with medical supply support. When

this was pointed out later to the Army chief of

staff during the Gulf crisis, he remarked

somewhat disingenuously that that must

mean there were no problems with medical

supply. Lt. Gen. (Ret.) William G. Pagonis,

USA, with Jeffrey L. Cruikshanks, Moving

Mountains: Lessons in Leadership and

Logistics from the Gulf War (Boston, Mass.:

Harvard Business School Press, 1992). Tel.

interview, Lt. Gen. (Ret.) Frank Ledford,

Nov. 12, 1997.

99. Brannon, after-action report, p. 6.

Howell interview, May 13, 1999. An

extremely large amount of medical supplies

arrived in the AOR just prior to the beginning

of the ground war. Interview, Maj. Robert

Munson, Aug. 12, 1997.

100. Brannon, after-action report, p. 47.

Knisely interview, Mar. 25, 1999.

101. GAO, Operation Desert Storm:

Problems with Air Force Medical Readiness

(Washington, D.C.: GAO/NSIAD-94-58,

Dec. 30, 1993), p. 11.

102. Gen. Sloan recalls the then commander of the Army’s Health Services Command,

Major General Winkler, discussing in the

early 1980s the concept of “clearing the battlefield” in contrast to the official Army medical doctrine of the time. Analyses of the

Beirut evacuation of Oct. 1983 apparently

figured in these discussions. Sloan interview,

Aug. 20, 1997. 

103. He also was clearly disappointed that

the AE system in the Gulf had not operated as

straightforwardly. Conditioning his perspective may have been the fact that the 44th provided medical backup to the various Army

special forces units whose home station was

also Fort Bragg. They generally relied on

early tactical evacuation of their casualties

because they deployed only “light” medical

capabilities with troops in their operations.

Although Foust’s views were expressed long

after these events, there is little reason to

doubt that he was reflecting his contemporary attitudes, especially in view of the

respect he manifested for Colonel Brannon

during the interview. Foust interview, Mar. 3,

1999.

104. Brannon recalled a flight surgeon

and an anesthesiologist accompanying the

first load of casualties from Howard and a

medical technician and another flight surgeon

flying on the second; however, the latter was

merely a passenger on the aircraft. Tel. interview, Col. (Ret.) Robert Brannon, USAF

MSC, Feb. 16, 1998. He explicitly took issue

with Mabry, Munson, and Richardson’s article, “The Wartime Need for Aeromedical

Evacuation Physicians,” that asserts one

physician accompanied each AE flight from

Howard. It should be noted, however, that the

authors relied on the same written source

rather than first-hand knowledge as had

Mabry in writing his unpublished paper.

105. Munson interview, Aug. 12, 1997.

Interviews, Maj. Gen. Earl Mabry, USAF

MC, Feb. 24, 1998 and Apr. 29 and May 3,

1999; Lt. Col. Farley Howell, May 10 and

13, 1994. As was perhaps natural given the

confusion about U.S. intentions in the immediate wake of the Iraqi invasion, selectees in

some cases were those least important to the

activities that released them for service in the

396

Notes
AOR. Mabry, unpublished mss, “The

Wartime Need for Aeromedical Evacuation

Physicians,” p. 8.

106. Mabry interviews, Feb. 24, 1998;

Apr. 29 and May 3, 1999. Tel. interview, Col.

Carroll Bloomquist, Feb. 29, 1998.

Bloomquist was the medical planner at MAC

during the crisis.

107. Brannon, after-action report, pp.

15–16. They also served as SMEs for the

flight personnel at these sites. Tel. interview,

Lt. Col. Farley Howell, USAF NC, June 18,

1999. Howell deployed from Pope after the

initial deployment of personnel from the 1st

AES, but worked closely with Brannon in

organizing and administering the 1611th.

108. Mabry, who is universally credited

with organizing the flight surgeons and using

them in a meaningful way, said in an interview years later that he found the flight surgeons billeted in Riyadh essentially doing

nothing. Mabry interview, Feb. 24, 1998. By

contrast, it is apparent that Brannon and his

staff saw little positive value for their operation from the presence of the flight surgeons’.

According to Mabry, the group, which he

dubbed “his little lost legion of flight surgeons” during the interview, sought his help

in finding more meaningful roles to play. Tel.

interview, Apr. 29, 1999. Lt. Col. Robert

Munson, one of these flight surgeons, largely

confirmed Mabry’s account of the lack of a

meaningful role played by the flight surgeons

until Mabry’s actions. Munson interview,

Aug. 12, 1997. Colonel Munson is a rated Air

Force pilot in addition to being a physician.

109. Army tactical medical doctrine

called for keeping no more than 60 percent of

the available beds in the field filled with

patients so that they could absorb surges of

fresh casualties within their available capacity. Tel. interview, Dr. Robert Joy, June 2,

1999. Mabry, Munson, Richardson, “The

Wartime Need for Aeromedical Evacuation

Physicians: The Air Force Experience During

Operation Desert Storm,” p. 944. 

110. Mabry interview, Feb. 24, 1998. Tel.

interview, Col. Londe Richardson, USAF

MC, June 9, 1999. Richardson was in the second group of flight surgeons deployed to the

AOR assigned to the AE system. He and Dr.

Munson were both assigned to Brooks when

ordered to the Gulf. Anticipating the kinds of

patients they might encounter in the AE system, they took courses in ATLS and ACLS at

Wilford Hall Hospital prior to deployment. 

111. Mabry, unpublished mss, “The

Wartime Need for Aeromedical Physicians,”

pp. 10–11. Mabry interview, Feb. 24, 1998.

Mabry, Munson, and Richardson, “The

Wartime Need for Aeromedical Evacuation

Physicians,” p. 944. Drs. Munson and

Richardson flew to Germany to recruit flight

surgeons for service in the AOR from among

the thirty to fifty who had been assigned there

for AE duty but were able to return only with

four because of bureaucratic problems.

Munson interview, Aug. 12, 1997; tel. interview, Munson, Feb. 12, 1998.

112. This liaison program was welcomed

enthusiastically by Army physicians.

Interviews, Mabry, Feb. 24, 1998, and

Munson, Aug. 12, 1997; tel. interview, Col.

Londe Richardson, USAF MC, June 8, 1999.

Richardson deployed from Brooks AFB with

Major Munson in the second group of flight

surgeons. Both took courses in ATLS and

ACLS at Wilford Hall Medical Center on

their own initiative prior to deployment.

113. Mabry, unpublished mss., “The

Wartime Need for Aeromedical Evacuation

Physicians,” p. 9. Mabry, Munson, and

Richardson detail several episodes, “The

Wartime Need for Aeromedical Evacuation

Physicians,” p. 944. The word “defer” was

chosen because the sociology of medical

flight crews that included augumenting flight

surgeons involved certain obvious tensions:

the known professional tensions between

doctors and nurses as well as the obvious

resentment flight nurses would almost certainly feel if they saw the physicians’ presence as an implied comment upon their professional competence. Several interviewees

397

Notes
who served in the Gulf acknowledged these

tensions.

114. Ibid., p. 11. The apparent enthusiasm

for volunteering among the flight surgeons

who were assigned outside the AE system

was such that the CENTAF surgeon, Colonel

Randolph, had to issue a directive in midFebruary to those assigned to the squadron

medical elements (SMEs) prohibiting SME

flight surgeons from augmenting aeromedical evacuation crews. Nanney, GWAPS,

Medical Support, p. 222. The mid-February

timing of this is somewhat curious in that the

U.S. forces and their allies were on the verge

of beginning the ground campaign. Because

high casualties were predicted, a reasonable

presumption would be that there would be a

requirement to aeromedically evacuate more

“green” patients with a corollary need for

more physicians to augment the regular medical flight crews. On the other hand, SMEs

might have been viewed as more critical to

Air Force operations because close air support required operation within the envelope

of many ground based weapons, and only

one physician was assigned to each SME

along with two medical technicians.

115. Ibid. Maj. Robert Munson, “Wartime

Need for an Aeromedical Evacuation

Physician,” “Mobile Hospital Units (And

Detachments),” Apr. 14, 1992, p. 95. 7th

Conference on Military Medicine.

116. The commander of the 5th MASH

noted that one of his predecessors had identified the airlift needed to deploy the MASH as

32 C–141s. Colonel Kenneth Steinweg,

“Innovation in the Desert: MASH Medical

Packages for Desert Warfare,” p.25.

117. Lt. Col. Eldon Edeus, “Medical

Mobility in the Desert,” “Mobile Hospital

Units and Detachments,” Apr. 14, 1992, pp.

4–5, 7th Conference on Military Medicine.

118. Ideus, “Mobility in the Desert,” p. 9;

Steinweg, “Innovation in the Desert pp.

18–25;” 2nd Lt. Patrick J. Bennett, “Design

and Implementation of the Forward Surgical

Element (FSE),” pp. 8–9. The 5th MASH

also broke out a forward surgical Team that

was also more mobile than the MASH in its

original configuration.

119. This role was taken on with apparent

gusto by the USCINCEUR, Gen. Jack

Galvin, USA, who was reported to have told

his staff that the response to any request for

support to CINCENTCOM was “The answer

is yes. What is the question?” Col. Robert M.

O’Brien, MS, USAF, and Lt. Gen. Alexander

Sloan, MC, USAF, “Medical Support to

Desert Shield/Storm: The USEUCOM

Surgeon’s Perspective,” The Journal of the

US Army Medical Department (Mar./Apr.

1992): 3. Gen. John Shaud, USAF, who was

Galvin’s chief of staff at Galvin’s headquarters in his role as Supreme Commander of

Allied Command, Europe, confirms that

Galvin directed the fullest possible cooperation with any request made upon the

European command and also acted as the

advocate for securing any cooperation from

the European allies needed to meet CENTCOM requirements. Tel. interview, Aug. 18,

1997.

120. O’Brien and Sloan, “The USEUCOM Surgeon’s Perspective,” p. 4.

121. Ibid.

122. U.S. Army doctrine identified “contingency hospitals” as those that became the

subject of active interest only on the outbreak

of hostilities. Sloan interview, Aug. 20, 1997.

The target number of beds for the USAFE

contingency system was originally 14,500,

but this planning had been overcome by

events in the Soviet Union. CINCUSAFE,

Gen. Oaks, had placed a moratorium on the

replacement of outdated war reserve materiel

that meant that many of the dated potency

items available were no longer useful when

the Gulf crisis began. Nanney, GWAPS,

Medical Support, p. 211.

123. Interview, LTG Charles Roadman,

USAF, MC, Air Force Surgeon General, Jan.

20, 1998. Tel. interview, Gen. (Ret.) Robert

Oaks USAF, Sept. 24, 1998. Nanney,

“Medical Support,” GWAPS, p. 211. Brig.

398

Notes
Gen. Charles Roadman, “Component

Command Surgeons and Planners–USAFE

Perspective,” 7th Conference on Military

Medicine, p. 263. At the time of this presentation, Roadman was serving as the

MAC/TRANSCOM Command Surgeon.

The lead medical personnel, 260 of the 332

required, did not depart David Grant Medical

Center at Travis AFB, Calif., for their assignment at Nocton Hall until Jan. 20, 1991.

310th USAF Contingency hospital, RAF

Nocton Hall, “Medical After-Action

Report–Operation Desert Storm,” Mar. 15,

1991. I am indebted to Maj. Gen. (Ret.)

William Greendyke, MC, USAF, for a copy

of this report. Apparently, the same type of

deployment schedule was followed by the

staffs assigned to the other three contingency

hospitals. Nanney, GWAPS, Medical

Support, p. 211.

124. Tel. interview, MG James Whinnery,

MC, ANG, Sept. 29, 1998. At Gen.

Roadman’s request, Gen. Whinnery became

17th Air Force Surgeon, filling one of the

three numbered air force surgeon’s offices

temporarily established by Roadman. This

decentralization gave the USAFE Surgeon

greater latitude to deal with larger policy

issues regarding USEUCOM’s medical support to CENTCOM.

125. H. T. Johnson interview, June 15,

1999.

126. Nanney, GWAPS, Medical Support,

p. 209. Roadman, “Component Command

Surgeons and Planners–USAFE Perspec -

tive,” p. 268, 7th Conference on Military

Medicine. Lt. Col. Joseph L. McGraw, MS,

USAF, “The Gulf War in Europe: An Air

Force Medical Review,” Perspectives on the

Gulf War, pp. 24–25. Sloan interview, Aug.

20, 1997. Sloan notes that the head of the

German military medical service told him a

telephone request would be met with an

immediate positive response. Lt. Col.

Christoph Veit, MD, and Maj. Stephan

Schoeps, MD, “German Medical Assistance

for US Forces During the Gulf Crisis: A

Stock-Taking of Lessons Learned,”

Perspectives on the Gulf War, p. 58. Both

German doctors were assigned to the Federal

Ministry of Defence. Perhaps indicative of a

certain wariness about the casualty figures

that the Joint Staff’s medical planning module was generating as well as his awareness

of resource constraints, Gen. Sloan used the

term “negotiate” long after the event when

discussing how the bed requirements for

USEUCOM were determined in discussions

with CENTCOM. Tel. interview, Apr. 23,

1999.

127. Roadman interview, Jan. 20, 1998.

Gen. Roadman said that he immediately

called in the commander of the 2d AES, part

of the worldwide AE system operated by

MAC. The 2d provided the medical crews for

the MAC C–9s assigned to Rhein-Main Air

Base that in turn provided the airlift capability for the AE System within the EUCOM

area of responsibility. Roadman’s characterization of his role reflects the fact that the

USAFE Surgeon had no formal control over

either the flight crews or C–9s that belonged

to MAC. Based on his queries of the 2d AES

commander, Roadman identified a number of

equipment deficiencies including a lack of

ventilators available for aeromedical evacuation.

128. As described in Chapter 7, a wartime

role for the MAC C–9 fleet had been agreed

upon between USCINCEUR and the MAC

commander in the mid-1980s as part of the

program to upgrade the medical support for

U.S. forces committed to NATO pressed vigorously by the DCINCEUR, Gen. Richard

Lawson. Interview, Lawson, July 29, 1997.

As noted earlier, the dispatch of C–9s to the

AOR had been rejected by the MAC commander for several reasons. One not usually

cited is the lack of sufficient range for the aircraft to have flown nonstop from the AOR to

European bases. I am indebted to the former

MAC commander, Gen. H. T. Johnson,

USAF, for pointing this out. Tel. interview,

June 15, 1999. If C–9s had actually been used

399

Notes
to evacuate patients from the AOR, a staging

base such as Cairo West would have been

necessary for refueling, and the additional

stop would have injected another delay in the

evacuation chain.

129. The Air Force Surgeon General, Lt.

Gen. Monte Miller, reportedly was particularly concerned. Tel. interview, Lt. Gen.

(Ret.) Alexander Sloan, Apr. 12, 1999.

130. Roadman, “USAFE Perspective,”

7th Conference on Military Medicine, p. 269.

131. Knisely interview, Mar. 25. 1990;

Nanney, GWAPS, Medical Support, pp.

211–12. The adoption of the “three day pass

through” was apparently a recommendation

of Gen. Roadman to Gen. Sloan. Ltr to the

author, Mar. 5, 1999, from Col. Carroll

Bloomquist. 

132. Tel. interview, Maj. Gen. P. K.

Carleton, MC, USAF, Jan. 27, 1999. Gen.

Carleton established a contingency hospital

at Seeb in the United Arab Emirates during

Desert Shield using host nation facilities

staffed chiefly by U.S. medical reservists.

Also see the discussion of “delayed primary

closure” by the very respected surgeon, Dr.

Kenneth G. Swan, who deployed to the Gulf

and unfavorably contrasted the surgical techniques he observed there with his experiences in Vietnam. Swan cites a five-day period following initial surgery and removal of

dead and damaged tissue (“debridement”) of

the wound after which final closure should be

accomplished. Swan was a very respected

surgeon, professor of surgery, and Chief of

the Section of General Surgery at Rutgers

Medical School. Kenneth G. Swan, MC,

USAR, “Heaton Lecture–Combat Casualty

Care,” Perspectives on the Gulf War, p. 7.

Roadman interview, Jan. 20, 1998. In his discussion of this issue, Gen. Roadman focused

on the clinical benefits to patients from

quickly reaching hospitals in the United

States where they could get final definitive

care.

133. The initiative for dedicating missions seems to have been Brannon’s, but it

was supported by CENTAF and CENTCOM, and tacitly, at least, by a senior AE

planner from MAC who had been deployed

to the European theater and who, according

to the Deputy CENTCOM Surgeon, helped

stimulate support for the idea at the CENTCOM Surgeon’s office unofficially–because

it was contrary to MAC policy–from his post

in Europe. Gen. Johnson reportedly approved

reserving a portion of the airlift support allocated to CINCENT with the proviso that

MAC would continue to provide aeromedical

evacuation on a retrograde basis for the time

being so as not to disrupt the flow of personnel and war materiel to the AOR. Tel. interview, Col. Ben Knisely, MSC, USA, June 20,

1999.

134. Interview, Col. (Ret.) Robert Joy,

MC, USA, Mar. 15, 1999.

135. Senior medical officers in the AOR

were intensely concerned to ensure that the

aeromedical evacuation system was capable

of moving large numbers of patients. Col.

Ben Knisely, the Deputy CENTCOM

Surgeon, recalled that Col. Tsoulos, the

Surgeon of CENTCOM Army forces,

expressed the view that the threat of chemical

weapons that could generate large numbers

of casualties quickly made it imperative to

use aeromedical evacuation to the COMZ to

reduce the patient population in the MTFs as

rapidly as possible. He argued that he would

even evacuate patients who would ordinarily

have been held in the AOR pending recovery

from minor wounds because clearing such

patients from MTFs in the combat zone

would provide the beds to deal with sudden

surges in the number of casualties. Knisely

interview, June 20, 1999. Mahlum interview,

June 21, 1999. Mahlum prepared the final

draft of the CONOPS in late December with,

to his surprise, Gen. Johnson looking over his

shoulder.

136. Contrary to GWAPS, the MAC

Command Surgeon’s representative to the

command’s crisis action team during Desert

Shield/Desert Storm reports that ten AESS

400

Notes
were available. Mahlum interview, Mar. 21,

1999. This is confirmed by General Johnson,

then the MAC commander who noted in an

interview long after the event that he had

pressured Boeing strongly to advance its

delivery schedule. Tel. interview, June 15,

1999. Mahlum was a medical planner with

long experience in AE serving in the MAC

Surgeon’s office during the Gulf crisis. The

senior medical planner at Scott, Col.

Bloomquist, confirmed Johnson’s direction

to get the shipsets in case they were needed,

and that the contractor, E-Systems, and the

MAC logisticians had ten sets ready to

deploy well before the ground war began. Ltr

to the author, Mar. 5, 1999. Interview, Col.

(Ret.) Ronald Priddy, USAF, Sept. 20, 1997.

Col. Priddy was assigned as Director of the

CRAF at MAC Hqs from 1989 to 1992, and

worked closely with Col. Bloomquist. As

early as late November, activation of the AE

segment of the CRAF had been proposed by

CENTCOM. Knisely interview, June 20,

1999.

137. Roadman, “Component Command

Surgeons and Planners–USAFE Perspec -

tive,” 7th Conference on Military Medicine,

pp. 270–71. Oaks interview, Sept. 24, 1998.

138. Nanney, GWAPS, Medical Support,

p. 218. Ltr to the author from Col.

Bloomquist, Mar. 5, 1999. Some twenty-four

attendees were present. Brannon’s afteraction report contains a brief discussion of

the conference decisions (pp. 22–23), but the

only indication of the meeting in Medicine in

the Gulf War is a picture on p. 67 of the conferees (photo provided by Col. Belihar).

139. Mahlum interview, June 23, 1999.

140. Ibid. Foust interview, Mar. 3, 1999.

Fischelli interview, June 28, 1999. Col.

Fischelli served as AE coordinator for the

southern region at Torrejon Air Base, Spain,

during Desert Shield/Desert Storm. The

GAO also noted a number of deficiencies in

medical regulating that its investigators had

uncovered and that participants have discussed freely with the author. GAO,

Operation DESERT STORM. Problems with

Air Force Medical Readiness, p. 9. As the

title suggests, this report is critical of many

aspects of Air Force planning and execution

of its role in medical support of CENTCOM

forces. However, the report appears to be

flawed in several respects, such as, investigators working a year or more after the end of

Desert Storm cited the one-physician/twomedical technician manning of the AELTs as

insufficient to maintain a twenty-four-hour

operation on the basis of interviews with “Air

Force officials.” However, Brannon’s afteraction report, which the GAO report otherwise cites frequently, specifically notes the

problem and indicates that additional personnel were assigned to AELTs or that AELTs

were combined whenever possible to allow

continuous operation. In fact, Brannon

includes a table (Table 3) showing the

strength of the nineteen AELTs deployed, and

all appear to have been augmented. Afteraction report, p. 3. Additionally, in some

cases, support for a critical finding appears to

be anecdotal, the assertion of a single anonymous (at least in the unclassified version)

individual.

141. Brannon, after-action report, pp.

27–28. Tel. interview, Mahlum, June 24,

1999. Brannon notes that he tried to get the

EUCOM JMRO to go to a contingency regulating system in early December but was

refused. When contingency regulating was in

fact directed, Brannon asserts that the

EUCOM JMRO required more information

than was usual in contingency situations, presumably because of the tracking system that

the USAFE Surgeon had established at the

direction of Gen. Oaks. This interpretation

accords with Gen. Roadman’s complaints at

the 7th Conference on Military Medicine in

April 1992, about the dearth of personal

information available on patients arriving

from the AOR.

142. The “push” terminology is Col.

Bloomquist’s Ltr to the author, Mar. 5, 1999,

from Col. Bloomquist. That both Bloomquist

401

Notes
and Brannon thought alike on the unreliability of medical regulating with DMRIS in the

circumstances attendant to CENTCOM

offensive operations may have also been due

to informal discussions between Scott and

Riyadh during December in message traffic

or by secure telephone. In his presentation to

the April 1992 conference at USUHS, Gen.

Roadman noted that, because of the contingency regulating system, the first time any

casualty from the AOR was known was when

he was processed into one of the USAFE

ASFs or medical facilities. “Component

Command Surgeons and Planners: USAFE

Perspective,” 7th Conference on Military

Medicine, p. 271. It should be noted that neither Belihar, Randolph, Roadman, nor, for

that matter, Tenoso, had any but tangential

experience with aeromedical evacuation

prior to the Gulf crisis.

143. Brannon, after-action report, pp.

22–24. King Khalid Military City was to be

the strategic hub for XVIII Corps, King

Khalid IAP the strategic hub for VII Corps;

and King Fahd IAP, Jubail IAP, and

Muharraq IAP were to share responsibility as

strategic hubs for the Marine Expeditionary

Forces (MEFs).

144. Sloan interview, Feb. 18, 1998;

Brannon interview, Feb. 2, 1999; interview,

Lt. Col. (Ret.) Philip Mahlum, June 24, 1999.

145. Ten missions were also dedicated to

strategic AE from Europe to the ZI. Mahlum

interviews, June 23 and 24, 1999. Also see

Nanney interview, Brig. Gen. Roadman, May

29, 1992. In an interview in June 1992,

Brannon stated that he had authority for “”fifteen C–141s preconfigured for AE; however,

he refers to eleven in his after-action report.

Nanney interview, Col. Robert Brannon,

MSC, USAF, June 26, 1992, p. 42.

146. Tenoso interview, Jan. 29, 1999.

Mahlum interview, June 23, 1999. In this

inter view, Gen. Tenoso said that he had intended to “dedicate” the aircraft in the precise

sense, putting red crosses on their tails and

thus under Geneva Convention protections.

147. Interviews, Sloan, Feb. 2, 1999;

Mahlum, June 24, 1999; Brannon, Feb. 18,

1999. Bloomquist, Ltr to the author, Mar. 5,

1999. Brannon, after-action report, p. 29.

According to Sloan, there was also a possible

misunderstanding whether the hub-to-hub

system was to go into effect immediately

when hostilities began or at an agreed-upon

level of casualties. EUCOM and MAC

believed the latter. However, the driving factor in the denial of the use of preplanned AE

missions was clearly the concern of MAC to

maintain the airlift priorities for operational

support to CENTCOM forces unless there

was an actual evacuation “emergency.”

Brannon still evidenced some frustration as

he recalled the situation many years later during the cited telephone interview with the

author and in an earlier interview with Dr.

James Nanney, June 26, 1992, pp. 41–43.

148. Nanney, GWAPS Medical Support,

pp. 220–21.

149. Ibid.

150. Brannon, after-action report, pp.

20–21, 58. Best and Tomich, Medicine in the

Gulf War, pp. 59–60. Tel. interview, Col.

Brannon, Feb. 16, 1998.

151. Brannon, after-action report, p. 25.

152. A joint task force composed of personnel from EUCOM and USAFE under the

leadership of the Deputy Command Surgeon,

Col. David Lam, MC, USAF, deployed to

Incirlik on Jan. 15, to organize medical support. Lam returned to EUCOM HQ on Mar.

8, but the joint task force revived when

Provide Comfort began. Best and Tomich,

Medicine in the Gulf War, pp. 116. 

153. Lt. Col. Joseph M. Harmon, III,

“Operation Provide Comfort: A Cry for

Help–The Military Role in Humanitarian

Aid,” Perspectives on the Gulf War, pp.

31–32. Dr. Joseph Leland, “Background

Paper, subj: Operation Provide Comfort, June

19, 1992, AMC/HO.

154. Cols. Stephen A. Jennings, MC,

USAF, and Daniel L. Cohen, MC, USAF,

and Lt. Col. Laura K. Corrow, et al.,

402

Notes
“Deployment of an Air Transportable

Hospital in Support of Allied Forces during

Operation Provide Comfort: April 29 to July

12, 1991,” Military Medicine, 158 (Mar.

1993): 136.

155. Best and Tomich, Medicine in the

Gulf War, p. 117.

156. Tel. interview, S/MSG Mark

Johnson, 439th AES (formerly the 74th

AES), June 28, 1999. Sgt. Johnson, an AE

medical technician assigned to the 74th AES,

AFRES, at Westover AFB, Mass., deployed

to the AOR on Feb. 3, 1991, and subsequently served for a month at Incirlik flying

aeromedical evacuation missions during

Provide Comfort. His deployment was confirmed by the 439th ART, Maj. David

Zamorski, in a telecon, June 28, 1999.

157. Ibid. Harmon, “Operation Provide

Comfort: A Cry for Help,” pp. 34–35.

Interview, Maj. Robert Hayhurst, MSC,

USAF, Mar. 11, 1998. Hayhurst had served

as AE liaison to the Navy at Bahrain, but was

detailed to Turkey by Brannon in late May to

provide the liaison function for Army forces

deployed into Iraq.

158. Msg., Personal from Gen. Galvin,

CINCEUR, for Gen. Johnson, CINCMAC,

subj: Provide Comfort, Aug. 14, 1991. Tel.

interviews, Maj. Wayne Olsen, MSC,

USAFR; and Maj. David Zamorski, MSC,

USAFR, June 28, 1999. Maj. Olsen was at

the time the senior ART of the 32d AEG

based at Kelly, and Maj. Zamorski held the

similar position for the 74th AES based at

Westover AFB, Mass., which provided the

medical flight crews. 

159. Quote is from Knisely interview,

June 20, 1999.

160. GAO, Operation Desert Storm:

Problems with Air Force Medical Readiness,

Dec. 30, 1993; GAO, Operation Desert

Storm. Full Army Medical Capability Not

Achieved (GAO/NSIAD-92-175, Aug. 18,

1992); GAO, Operation Desert Storm.

Improvements Required in the Navy’s

Wartime Medical Care Program

(GAO/NSIAD-93-189).

161. Interview, Dr. Robert Joy, Apr. 19,

1999. 

162. Quoted in GAO, Operation Desert

Storm. Problems of Air Force Medical

Readiness, p. 9.

163. Ferguson interview, Jan. 7, 1992;

Sloan interview, Feb. 18, 1998; Bloomquist

ltr to the author, Mar. 5, 1999.

164. Nanney interview, Roadman, May

29, 1992, p. 14. Gen. Roadman expressed the

belief that there could have been a shortage of

aircraft that, by implication, could have

caused the AE system to “backlog,” if not to

“fail.” Interestingly, Roadman brought up the

opening scene of Gone with the Wind with

thousands of wounded Confederate soldiers

lying in the streets of Atlanta on litters, p. 8.

Chapter Ten

1. Many of the senior participants saw the

post–Gulf War period as a fruitful opportunity to establish “jointness” more fully in the

U.S. armed forces. In 1992, the author attended a briefing at the Johns Hopkins Research

Laboratory by a group of veteran analysts

employed by the Center for Naval Analysis

(CNA) to analyze the Navy’s performance

during Desert Shield/Desert Storm. One of

them commented that there appeared to be a

consensus among senior officer veterans of

the Gulf War who CNA had interviewed and

who favored more interservice joint activity

on the basis of their Gulf experience.

According to the analyst, these officers

opined that these operations had opened a

significant chance to “push” jointness in the

services, but that the “window” for success

was only about five years long. This was

because, after that time, those leading the services would more strongly reflect the service

“parochialism” that they had acquired serving with their services as junior officers during the Gulf crisis. Symptomatic of the

increased emphasis on jointness was Gen.

Powell’s sponsorship of The Joint Forces

403

Notes
Quarterly, which began publication in 1992

at the National Defense University where the

author was on staff.

2. These assertions were particularly

prevalent in comments quoted in Best and

Tomich, Medicine in the Gulf War, but also

implicit in some of the comments in the presentations by medical corps veterans in 7th

Conference on Military Medicine.

3. See Chapter 9. The comments were

made before medical veterans of the Gulf

from all services at the 7th Conference on

Military Medicine a year after the war.

4. Tel. interview, Capt. Gary Breeden,

MSC, USN, Aug. 30, 1999. Other aspects of

the tactical AE system had their critics. The

commander of Fleet Hospital Five in the

AOR was one of those hospital commanders

who faulted the Air Force for requiring MTFs

to provide an accompanying medical attendant if medical or operational circumstances

compelled an MTF to seek aeromedical

evacuation of patients who were not completely stable. His somewhat exasperated

comment to fellow conferees at the 7th

Conference on Military Medicine apropos

this Air Force policy was that “if the Air

Force is responsible for medevacs, they

should do medevacs!” Capt. Thaker Patel,

MC, USN, “Fleet Hospital Five,” 7th

Conference on Military Medicine, p. 88.

5. Tel. interview, Jan. 29, 1999. Tenoso’s

comment was offered at the end of the

lengthy interview and a specific discussion of

how he had planned to handle the projected

heavy initial wave of casualties requiring tactical aeromedical evacuation. His spontaneous recollection has been confirmed by the

then Deputy CENTCOM Surgeon, Col.

Knisely, who reports that extensive discussions preceded Tenoso’s acquiescence in

reserving a substantial part of the tactical airlift fleet for AE during the initial ground

attack. According to Knisely, it was predominantly the issue of the possible need to evacuate large numbers of casualties resulting

from Iraqi chemical attacks that caused the

reservation of some thirty-five C–130s at the

beginning of the ground war. He confirms,

however, that operational requirements

caused these aircraft to be assigned to other

tasks almost immediately. Tel. interview,

Sept. 26, 1999.

6. General Boomer’s comments regarding the inadequacy of Marine medevac capability were offered with some vigor according to the record; those of the Deputy CENTCOM Surgeon regarding CENTCOM’S plan

to use Air Force C–130s for evacuating

marine casualties in a recent interview

reflected a total lack of faith that Marine

opportune airlift could accomplish the

required medevac.

7. Perhaps the best illustration of the difficulties inherent in relying on retrograde airlift is embodied in the so-called Grow

Escadrille of 1944. Without the U.S. Strategic

Air Forces (USSTAF) Surgeon, General

Malcolm Grow, being able to press into service fortuitously uncommitted single-engine

“Norsemen,” a dangerous backlog of patients

on the east bank of the Rhine during the invasion of Germany could not have been eliminated. The troop carrier C–47s that had been

performing aeromedical evacuation had all

been committed to the support of the advancing allied ground forces. (See Chapter 5.) 

8. Tel. interview, Lt. Gen. Tenoso, July

31, 1999. Tel. interviews, Maj. Gen. James

Whinnery, ANG, Sept. 29, 1998, and July 31,

1999. General Whinnery is married to an exflight nurse. Tenoso indicates that these discussions produced no directives or policy

changes. Not unreasonably because very few

battle casualties evacuated by air required

that a physician attempt any really serious

emergency medical interventions while in

flight during Desert Storm, some observers

whose attitude was generally conditioned by

the flight nurses’ greater experience and

knowledge of aeromedical evacuation than

the AE flight surgeons assigned to the AOR

questioned the very need for carrying physicians. Howell tel. interview, May 10, 1999.

404

Notes
Although not questioning the presence of the

flight surgeons on board, General Tenoso

noted in the just cited interview that he tended to sympathize with the flight nurses for the

same reasons. 

9. Tel. interview, Lt. Col. Margaret

Richey Raffa, NC, USAF, Aug. 23, 2000.

10. After-Action Report Operation

RESTORE HOPE, p. 2. Intratheater airlift

was generally performed by C–130s but New

Zealand C–748s, which were equipped with

litter brackets, were occasionally also used

when it was impossible to generate a C–130

for an AE mission; Howell interview, Apr. 1,

1998. Tel. interview, Lt. Col. John Felins,

MSC, USAF, Feb. 2, 1999. Felins deployed

to Mogadishu with the 1st AES. Interview,

Col. Courtney Scott, MC, USAF, Feb. 24,

1998. Operation RESTORE HOPE Theater

AE System Briefing, [Dec. 4, 1992; date of

the briefing is cited in the after-action report].

The definition is from AMC Regulation 164-

1, which cited a definition promulgated by

the JCS Medical Steering Committee in 1985

for wartime movements of patients. The

AMC regulation is quoted by Thomas

Chester, Aeromedical Evacuation After

Action Report, Exercise Knightly Rogue,

June 1, 1994, Attachment 6. I am indebted to

Lt. Col. Susan Konczal for a copy of this

report.

11. The twelve categories and the restrictions on patients with those conditions are

briefly described in Lt. Col. Carl J. McCann,

MSC, and Capt. Catherine D. Young, NC, “A

PDR to Conus Aeromedical Evacuation,”

USAF Medical Service Digest (March–April

1982): 3–4.

12. Tel. interview, Col. (Ret.) Sarah

Wright, NC, USAF, Sept. 5, 2000. Col.

Wright directed the AE cell in the TACC

from Feb. 1992 to June 1995. Also see Lt.

Col. Phyllis J. Hansen, NC, USAF, “Safe

Practice for Our Aeromedical Evacuation

Patients,” Military Medicine, 152 (June

1987).

13. Until Oct. 1, 1988, MAC retained the

status it had been given in 1994 of a “specified command,” that is, a single service command performing a joint function whose

commander was a co-equal “CINC” with the

commanders of overseas joint theater commands such as USEUCOM or USPACOM.

After Oct. 1, 1988, the commander of MAC

and its successor, AMC, were technically no

longer CINCs, although the term appears to

have been used throughout Gen. Johnson’s

tenure in regard to his status as MAC/AMC

commander. Betty Kennedy, Point Paper,

Nov. 8, 1996, Subj. Evolution of Roles and

Missions Authorities in AMC/USTRANS -

COM, 1941–1994. AMC/HO.

14. HQ MAC, Scott AFB, Illinois, Anne J

to CINCMAC OPORD 01-EX, “Command

Relationships,” copy, n.d. AMC/HO. The

document notes that the command relationships described are effective Oct. 1, 1988,

with the U.S. Transportation Command as a

unified command and Military Airlift

Command as a service component. After that

date, MAC no longer was a “specified command,” like the U.S. Army Forces Command

(FORSCOM).

15. Maj. Thomas Fraley, HQ MAC/XOC,

Point Paper, subj: Civil Reserve Air Fleet

(CRAF) Aeromedical Evacuation (AE)

Segment, Mar. 11, 1992. Files: AMC H/O.

16. Some seven years later, Col. Brannon

still expressed frustration with the way medical regulating had been conducted during

Desert Storm. Tel. interview, Feb. 16, 1998.

Concerns with medical regulating during

Desert Storm were not confined to the Air

Force, as the critical comment by the commander of the 44th Medical Brigade cited in

the last chapter indicated. In a recent interview, the former Deputy CENTCOM

Surgeon stated that, in his opinion, the inadequacies of medical regulation were the most

serious issue that surfaced with regard to

aeromedical evacuation during the Gulf crisis. Tel. interview, Col. (Ret.) Benjamin

Knisely, MSC, USA, Sept. 26, 1999. 

17. Tel. interviews: Col. Bloomquist, July

405

Notes
1999; and Lt. Col. Mahlum, Aug. 20, 1999.

Breeden interview, Aug. 30, 1999. According

to Captain Breeden, the TRANSCOM SG

staff analysis of the USEUCOM JMRO medical regulating during Desert Storm showed

that 60 percent of the patients went to a different aerial port of debarkation (APOD) in

the COMZ than that serving the MTF designated to receive them and that 50 percent of

them were delivered to APODs in the wrong

country. Tel. interview, Sept. 2, 1999.

Bloomquist indicated that, in retrospect,

when the “push” system was agreed upon in

Riyadh in early January, the participants

departed without a firm enough understanding when it was to go into effect vice the

DMRIS normal contingency procedures. 

18. Interview, Lt. Gen. (Ret.) Alexander

Sloan, MC, USAF, Aug. 20, 1997.

19. Military Airlift Command, Calendar

Year 1990, Vol. I: Narrative and Appendices

(Scott AFB, Ill: Office of History, MAC,

Dec. 19, 1991), pp. 71–75. AMC H/O.

20. With broad responsibilities for

TRANSCOM’s varied operations that transcended those of his parent Air Force command, MAC, Gen. Tenoso recalled only once

in his tenure as J–3 involving himself with

AE matters, and this was largely by chance.

During a routine review of a proposed budget

submission from TRANSCOM’s airlifters,

Tenoso noted that no money had been allocated for MASFs, the essential holding element through which patients of all services

engaged in contingency operations entered

the Air Force aeromedical evacuation system, and he caused the budget to be revised

to include the necessary funds. Tenoso tel.

interview, July 30, 1999.

21. In a recent interview, Col. Knisely, the

Deputy CENTCOM Surgeon, noted that the

then Col. Carleton was an important participant in discussions of AE with the CENTCOM and CENTAF surgeons. Tel. interview,

Sept. 26, 1999. During the post-Gulf deliberations on how to improve AE at TRANS -

COM, Carleton was asked to comment on an

assessment of the AE system by the senior

MAC staff director charged with its development by Gen. Johnson. Ltr, Carleton to Col.

Charles E. Maloom, HQ MAC/QSR, Sept.

16, 1999, copy to Roadman. It seems probable that Roadman, new in his job, had asked

Maloom to send a copy of the assessment to

Carleton for his comment. I am indebted to

Carroll Bloomquist for a copy of this letter.

22. Tel. interview, Lt. Col. Philip

Mahlum, June 24, 1999.

23. Tel. interview, H. T. Johnson, Sept. 2,

1999. Breeden reports that Johnson briefed him

and other members of the TRANSCOM

Surgeon’s office after Breeden’s arrival in July

1991 that he was bringing an outstanding officer

on board within several months to direct their

efforts. Tel. interview, Breeden, Aug. 8, 1999. 

24. Several members of the MAC

Surgeon’s staff during Desert Shield and

Gen. Johnson himself have indicated that one

reason he dispatched the MAC Deputy

Command Surgeon, the then Col. Mabry, to

Riyadh to serve as an AE advisor to the

CENTCOM Surgeon was to provide Johnson

with a direct informal source of information

on how the AE system was functioning.

25. Johnson interview, Sept. 2, 1999.

26. Rutherford’s comment is part of an

annotation he made on a memo for CINCMAC from Roadman, subj: Aeronautical

Assessment Report, Sept. 17, 1991, in which

the Vice CINC indicated the importance

Johnson attached to the subject and that “we

may need to discuss the subject.” I am indebted to Carroll Bloomquist for a copy of this

report, which shows Johnson’s initial.

27. Ltr, subj: USTRANSCOM Joint

Casualty Evacuation Working Group

(JCEWG). Attendees included representatives from the USAF SG, the theater commanders, the JCS–J4 Medical Readiness

Division, ASMRO, and the theater JMROs.

28. Cdr. Gary Breeden, Point Paper, subj:

Results of Joint Casualty Evacuation

Conference, Oct. 25, 1991. AMC H/O Files.

Breeden interview, Aug. 19, 1999.

406

Notes
29. Breeden Point Paper, Oct. 25, 1991.

Tel. interview, Knisely, Sept. 27, 1999.

Knisely confirms the conferees’ positive

response to the TRANSCOM proposal to

assume responsibility for medical regulating,

which he applauded. The “incestuous” comment seems curious because the Gulf experience with which all present were certainly

familiar cried out for better integration of the

two functions. 

30. “Staffing” a proposal involves securing agreement and/or comments on a proposed course of action from those who it may

affect or senior officials whose approval is

required before the official with authority to

make the final decision does so.

31. Ibid.

32. Staff Summary Sheet (SSS), Feb. 24,

1992, Subj. Draft MedReg Proposal for

Preliminary Coord Release to Geo CINC

Sgs, Roadman to Gen. Johnson. Roadman

recommended that the CINC approve transmitting copies of the draft proposal to the

geographic CINC SGs and the Forces

Command (FORSCOM) SG for “preliminary screening and any comments” as

TRANSCOM had agreed to do at the earlier

conference hosted by J–4. Breeden prepared

the SSS. Breeden papers.

33. Ltr, Lt. Gen. Dane Starling, USA,

DCINCTRANS, to Lt. Gen. Henry Vicellio,

Dir. Joint Staff (DJS), Apr. 13, 1992, Subj.

USTRANSCOM Proposal To Improve

Intertheater Medical Regulating. Breeden

papers. The USAF served as the administrative executive agent for the JCS, who,

according to Gen. Roadman, had not exercised OPCON over ASMRO allowing the

USAF SG to take over OPCON by default.

Ltr, Roadman to RADM Joseph Smyth,

USN, MC, Dep. Dir. for Medical Readiness,

J–4. Breeden papers.

34. Ltr, Roadman to Smythe, June 1,

1992, subj: ASMRO Ownership; Ltr,

Roadman to Smythe, June 1, 1992, subj:

Response to USAF Planner’s Memo #357-

92. Breeden papers.

35. Ibid.

36. Joint Staff Action Processing Form

prepared by Maj. Kirschner for the DJCS, Lt.

Gen. Henry Vicellio, USAF, June 30, 1992,

subj: USTRANSCOM Proposal to Improve

Intertheater Medical Regulating Worldwide;

DJCS Memo for DCINCTRANS, July 6,

1992, subj: USTRANSCOM Proposal to

Improve Intertheater Medical Regulating

Worldwide. Breeden papers. The

TRANSCOM DCINC Gen. Starling, had

specifically requested that the JCS approve

the TRANSCOM proposal “in concept” once

concurrence had been obtained from the services and theater commands so that joint

working groups could begin the necessary

work of drafting new DOD directives and

make out-of-cycle manpower requests that

the ASD/Health Affairs had already indicated

he would support. Ltr, Starling to Lt. Gen.

Vicellio, DJCS, April 13, 1992, Subj.

USTRANSCOM Proposal to Improve

Intertheater Medical Regulating Worldwide.

Breeden papers.

37. Betty R. Kennedy, Point Paper, subj:

Aeromedical Evacuation Historical

Precedents, April 6, 1998, AMC/HO. Point

paper, n.d., Subj. Significant Conversational

Issues, 3rd Qtr FY 96, AMC/HO. Breeden

Interview, Aug. 19, 1999. According to

Breeden, the term “execution” was inserted

into the system’s title to preclude development of TRAC2ES being assigned to the

Defense Information Systems Agency

(DISA), to whose jurisdiction the ASD/C3I

had decided to assign all new C3I systems

development in keeping with the objectives

of Strassman’s Corporate Information

Management initiative. Breeden interview.

38. Tel. interview, Lt. Gen. Charles

Roadman, Aug. 5, 1999. When the author

queried Gen. Roadman about the detailed

development of the TRAC2ES Program,

Roadman directed the author immediately to

Capt. Breeden. According to one of

Roadman’s experienced staff officers who

participated in the initiative, the general

407

Notes
called Breeden and the small group of staff

members he directed as “the Wolf Pack,”

because he could turn them loose to do a job

with minimal supervision. Tel. interview, Lt.

Col. Mahlum, Aug. 20, 1999. In a separate

interview, Breeden lauded the aggressiveness

of his group in pursuing the general’s agenda

and also cited the command surgeon’s use of

this nickname for the group. Interview, Capt.

Gary Breeden, Aug. 19, 1999. For a brief

description of the Corporate Information

Management initiative by its author, see Paul

A. Strassman, “Corporate Information

Management: Streamlining A Cottage

Industry,” Defense (Nov.–Dec. 1991): 18–20.

Prior to his appointment in the Defense

Department, Strassman had been an extremely successful executive at Xerox.

39. Dr. James K. Matthews, and Dr. Jay

H. Smith, interviewers, Oral History, General

Hansford T. Johnson, USAF, CINC, U.S.

TRANSCON and AMC (Scott AFB, Ill:

Offices of History, TRANSCOM and AMC,

Dec. 1992), pp. 77–78. According to one of

the members of Roadman’s staff, he appeared

to arrive with a commitment to TQM, which

he demonstrated in a number of ways. Not

the least of these was funding classes for

some of his staff to learn about this management system, but also by his continuous

emphasis on it during his tenure as the dualhatted command surgeon. Tel. interview, Lt.

Col. (Ret.) Philip Mahlum, Jan 31, 2000.

Mahlum’s view of the SG’s commitment to

TQM is confirmed by Roadman’s senior

MAC staff officer responsible for AE who

said in a recent interview that he had not

heard much about the movement until

Roadman was assigned and “brought TQM

to the forefront of the TQM activities [in the

Command].” Tel. interview, Carroll Bloom -

quist, Feb. 1, 2000.

40. TQM was a management system

developed by W. Edwards Deming, an

American whose ideas were first put into

practice in Japan. Demings’ ideas began to be

adopted widely by top U.S. companies in the

1980s, notably first by the Ford Motor

Corporation, as it began to search for better

ways to compete against what came to be

known ruefully as “Japan, Inc.,” because of

the Japanese government’s directing role in

the Japanese economy. Deming formulated

“fourteen points” with what one biographer

characterized as the “modest goal” of creating a management equivalent of the Ten

Commandments. These have been boiled

down to five by some successful management consultants. The words “process” and

“quality” are key words found in discussions

of TQM. Good discussions of TQM are to be

found in The Man Who Discovered Quality:

How W. Edwards Deming Brought the

Quality Revolution to America–The Stories of

Ford, Xerox, and GM (New York: Random

House Times Books, 1990), and Warren H.

Schmidt and Jerome P. Finnigan,

TQManager: A Practical Guide for Mana -

ging in a Total Quality Organization (San

Francisco: Jossey-Bass Publishers, 1993). 

41. Breeden interview, Aug. 19, 1999.

Staff Summary Sheet, Gen. Roadman for

CINC TRANS (Fogleman), Subj. Approve

Recommendations to Establish GPMRCASMRO, AECC, & Parts of AMC SG, Apr.

18, 1994, with Gen. Fogleman’s signature of

approval. AMC/HO. Gen. Johnson also had

his senior staff sit through TQM classes as

part of his program to impart “quality” to the

TRANSCOM mission, and his successor,

Gen. Ronald Fogleman, organized the Joint

Transportation Corporate Management

Information (CIM) Center (JTCC) within

TRANSCOM to use CIM techniques to

guide evolution of the defense transportation

system. Mahlum, tel. interview, Jan. 31,

2000. General Ronald R. Fogleman: An Oral

History (Scott AFB, Ill: TRANSCOM

Research Center, Mar. 1995), p. 71. One of

Johnson’s senior staff during Desert

Shield/Desert Storm, Gen. Walter Kross,

Johnson’s J–3/4, and later CINCTRANS

from 1996 to 1998, was still strongly supportive of the JTCC in a lengthy interview in

408

Notes
1998 during which he also repeatedly

stressed the need for continuous process

improvement and the use of the proper “metrics,” that is, the measurement standards that

derive from the continuation of the TQM

approach that began with Johnson, to evaluate process changes. General Walter Kross,

Oral History (Scott AFB, Ill: TRANSCOM

Research Center, Oct. 1999), pp. 66–67,

96–99. Money to support the TRAC2ES

workshops was obtained from a number of

different agencies in addition to that obtained

from Strassman’s office. Mahlum, tel. interview, Jan. 31, 2000.

42. Reports of the three CIM workshops

were bound together and published under the

title Corporate Information Management

(CIM): Administrative Support of Medical

Evacuees. Regulate and Evacuate Patients

Workshops (Arlington, Va.: SRA Corpora -

tion, 1993). SRA Corporation conducted

these workshops for the TRANSCOM Staff.

Breeden documents.

43. Executive Summary, Administrative

Support of Medical Evacuees Business

Process Improvement Baseline Workshop,

Regulate and Evacuate Patients Baseline

Workshop Report (Arlington, Va: SRA

Corporation, CIM-92-787-016-002, Dec. 31,

1992), p. 1–1. 

44. Point Paper, “Significant Conversa -

tional Issues, 3rd Qtr FY 96,” p. 28. Breeden

interview, Aug. 18, 1999.

45. Inspection Report 93-INS-13,

Medical Mobilization Planning and

Execution, Sept. 30, 1993, pp. 160, 162.

46. Lt. Col. Clayton Chapman, Chief,

Special Ops Planning, DCS/Quality Support

and Readiness (QS&R), Aeromedical

Evacuation Assessment Report to CINCMAC, transmitted to CINCMAC by a Staff

Summary Sheet (SSS) signed by Brig. Gen.

Donald Loranger, DCS/QS&R, Sept. 17,

1991. Gen. Johnson has annotated the SSS as

well as the report itself with comments in

pen. I am indebted to Carroll Bloomquist for

a copy of the report and a covering memo

dated Sept. 27, 1991, to Johnson responding

to the CINC’s comments on the SSS.

Indicative of Johnson’s objective of changing

attitudes within his command and “instilling

quality” performance throughout, he had

redesignated the MAC Inspector General as

the DCS/QS&R. The charter for the IG called

for him to visit MAC units to evaluate their

ability to perform their missions, and

Johnson wanted him to act as the “catalyst”

for quality on his visits. The name change

was shrewd because the MAC IG conducted

operational readiness inspections (ORIs) for

the MAC commander, which meant that the

IG was traditionally viewed warily by MAC

wing commanders because they could be

relieved of their commands if their wing

failed an ORI. Oral History, General

Hansford T. Johnson, pp. 75–77. (The attitude is exemplified by the wry joke that circulated in the command section of the 60th

MAC Wing when the author was DCO for

operations. This identified the two biggest

lies ever told as the IG’s comment to the wing

commander when he lands with his ORI

team that “we’re here to help you,” and the

latter’s response of “we’re glad to have you

here.”) While presumably sharing Johnson’s

interest in quality, Headquarters USAF, took

a dimmer view of the name change, and,

effective Aug. 1, 1992, the QS7R once again

became the (now) AMC IG.

47. A specially constituted self-inspection

team from the 375th AAW, which, prior to

the autumn 1990 reassignment of the mission

to the MAC Surgeon, had controlled MAC’s

AE forces worldwide.

48. AE Assessment Report, Executive

Summary. The medical planners were Maj.

Philip Mahlum, MSC, and Maj. Theresa

Heckman, a flight nurse, both of whom

worked for Col. Bloomquist who was dualhatted as a member of the Surgeon’s staff of

both TRANSCOM and MAC. Dr. James

Nanney interview of Col. Bloomquist, May

28, 1992. S/G HO Files.

49. Comments are handwritten on the

409

Notes
Sept. 17, 1991, SSS transmitting the assessment report. 

50. Ibid. Johnson printed “THE

REQUIREMENT” in capital letters followed

by an exclamation point. Ledford, the Army

Surgeon General, had expressed the fear that

the Air Force’s successful evacuation of critical patients from Howard AFB immediately

after receiving emergency surgery might

appear to be an acceptable model for medical

support of future contingencies. He feared

that this misapprehension could then cause

an unwarranted reduction in deployed higher

echelons of care when their absence at

Howard AFB was really dictated by operational considerations that overrode good

medical practice. See Chapter 8.

51. Ibid.

52. Self-perception of greater status

because of the work that one person does

compared to that performed by colleagues

within the same organization is certainly not

uncommon within bureaucratic organizations. Because the vast majority of MAC AE

units comprised reservists of various sorts,

those concerned with the command’s primary mission of strategic airlift probably were

indifferent if not mildly biased toward them.

When the author was discussing his first

assignment to MAC with the colonels’

assignment officer in the Pentagon, the latter

made it plain that assignments to MAC’

strategic airlift wings were more desirable

because they were part of what he termed

“Big MAC.” There, he asserted, opportunities for the command of operational units and

promotions were better than in “Little

MAC,” the various nonairlift organizations

that were part of the airlift command. The

375th was removed from the MAC AE

squadrons’ chain of command on Oct. 1,

1990, during Desert Shield. However, Gen.

Johnson’s concerns predated the Gulf crisis.

MAC History Office, MILITARY AIRLIFT

COMMAND, CALENDAR YEAR 1990.

Vol. I: Narrative and Appendices, Dec. 19,

1990, p. 71. AMC Archives. Mary D. Hebert,

History of the 375th Military Airlift Wing

(MAC); 1 July–31 December 1190, Vol. I:

Narrative, p.5.

53. Memo for CINCMAC from Brig.

Gen. Charles Roadman, subj: Aeromedical

Evacuation Assessment Report, Sept. 27,

1991.

54. Ibid.

55. The CMMS is discussed in MAC

Office of History, Anything, Anywhere,

Anytime, pp. 171–79.

56. Lt. Gen. Henry Viccellio, USAF,

“Mobility Requirements Study Briefing,”

Mar. 13, 1992. Viccellio’s presentation was

part of a session of the Washington Strategy

Seminar on “Power Projection and the Gulf

War.” A copy of Viccellio’s briefing slides

and a summary of his oral presentation is in

the possession of the author who attended the

session. The projection was to be for the 1999

timeframe with the intent of affecting the FY

1993 budget.

57. A Strategic Plan for the United States

Transportation Command Surgeon’s Office

(Scott AFB, Ill: TCSG, May 1, 1993), p. 1.

58. ASMRO would soon be combined

with the AECC at Scott to form the global

patient movement requirements center

(GPMRC). The deployable regulators were

part of the joint transportation reserve, and

they were eventually molded into a UTC for

TPFDD tasking. Ltr, Col. Bloomquist, Feb.

4, 2000.

59. Ibid., pp. 2–3. Included in the required

exercises were those that supported

FORSCOM if the Integrated CONUS

Medical Mobilization Plan was implemented. A memo for the service secretaries and the

Chairman JCS, among others, from Secretary

of Defense Cheney, Subj.: Strengthening

Department of Defense Transportation

Functions, was issued on Feb. 14, 1992, giving CINCTRANS combatant command over

the TRANSCOM components in peace as

well as wartime. DOD Directive 5158.4, Jan.

8, 1993, subsequently confirmed the new

authority of CINCTRANS.

410

Notes
60. Ibid., p. 2.

61. Tel. interviews, Philip Mahlum, Jan.

31 and Mar. 28, 2000. 

62. The quotation is from a book extolling

TQM written by General Creech who after

retirement served as a successful management consultant. Creech, The Five Pillars of

TQM, p. 121. Included in the front of the

book are words of praise from experts like

Peter Drucker, Tom Peters, Rosabeth Moss

Kanter of the Harvard Business School, as

well as General McPeak who wrote that the

“overarching factor in our great success in

the Gulf War” was the Air Force having followed Creech’s TQM concepts. As Gen.

McPeak’s comments suggest, the Air Force

heavily subscribed to TQM during his tenure

as chief of staff, and a TQM “center” was

established at Maxwell AFB, which is home

of the Air Force’s Air University.

63. Johnson Oral History, p. 77.

Johnson’s successor as CINCTRANS/

Commander AMC, Gen. Ronald Fogleman,

characterized his predecessor as a “true

believer” regarding the value of applying

TQM principles, and, while Fogleman had

continued the TQM emphasis of his predecessor to help shape improvements in his

dual commands during his tenure, he had

sought to “operationalize it.” Tel. interview,

June 28, 2000.

64. Lt. Gen. Alexander Sloan, the former

USEUCOM Surgeon during Desert

Shield/Desert Storm who served as Air Force

Surgeon General from late 1991 until 1994,

indicated in a recent interview that he also

stressed TQM during his tenure. Tel. interview, June 30, 2000. TQM principles were

also put into play in other venues, including

the line units of the ARC. Queried about his

knowledge of TQM, one ANG operations

group commander who had taken his C–130

unit to the Gulf War, stated in a recent interview that every commander in the early

1990s had to deal with the emphasis on

TQM. Tel. interview, Col. Ronald Hale,

ANG, Mar. 7, 2000. In another recent interview, an Air Force nurse practioner stationed

at Minot AFB in the mid-1990s reported that

TQM principles were applied to the operation of the Air Force Medical Service in the

field and were even part of the accreditation

process by a visiting hospital accrediting

organization at a northern SAC base to which

she had been assigned. Interview, Capt.

Barbara Tuitele, NC, USAF, Feb. 2, 2000. 

65. The timing of General McPeak’s

actions more than the fact that there would be

changes in the Air Force’s major command

structure was somewhat unexpected. The

creation of two new commands had been discussed among the Air Force’s three- and fourstar officers in the early spring of 1991, but

were envisioned as occurring in 1995. Air

Mobility Command (Provisional) History, 15

January–31 May 1992, Vol. 1: Narrative and

Appendices (Scott AFB, Ill: Office of

History, Air Mobility Command, June 29,

1993), pp. 5–6.

66. McPeak vigorously denied in his endof-tour interview that the end of the Cold

War, per se, was the catalyst for Air Force

reorganization in his mind. He asserted that

what he wanted to do “was to take a very

good, world-class organization, the best Air

Force in the world, and notch it up, keep it

climbing.” General Merrill A. McPeak End

of Tour Interview (Bolling AFB: AF History

and Museums Program, 1995), pp. 3–4.

67. Lt. Col. (Ret.) Mark Hamilton, MSC,

USAF, former AMC SGX, agreed with this

interpretation in a tel. interview Feb. 25,

2000.

68. Air Mobility Command (Provisional)

15 January–31 May 1991, pp. 2–3. 

69. It is apparent from the early discussions within the provisional AMC staff that

they were confused about exactly what

responsibility for AE the new command

would retain when it was “stood up” as the

MAC successor. For example, Betty

Kennedy, Interview of AMC (P) Commander

and key staff, Subj. “Combatant Command

(COCOM) and Force Assignment,” Mar. 11,

411

Notes
1992. AMC/HO. Generals Johnson and

Roadman had briefed the (COFS the week

before on March 4. The materials that were

presented to him included an executive summary of the first AE strategic plan and an AE

“white paper.” I am indebted to Col.

Bloomquist for a copy of the complete staff

“package,” which includes draft slide copies

for the Mar. 4 briefing attached to a Staff

Summary Sheet, Gen. Roadman for the

AMC Commander, Subj. Aeromedical

Evacuation (AE)–The Future (AE Strategic

Plan), Feb 17, 1992.

70. Lt. Col. Mark Hamilton, Position

Paper on Fixed-Wing Aeromedical

Evacuation and Proponency, copy n.d. (ca.

Jan. 1996). I am indebted to Carroll

Bloomquist for a copy of this memo.

Hamilton had replaced Bloomquist on the

AMC SG staff. Bloomquist, tel. interview,

June 25, 1998. Generals Johnson and

Roadman went to Washington on Mar. 4,

1992, to brief the CSAF on the AMC case for

retaining administrative command of the

aeromedical airlift and evacuation squadrons,

which he rejected. They had been advised by

their staffs that the USAFE and PACAF commanders had indicated that they did not want

administrative command, which would carry

with it responsibilities for training, policy and

doctrine, equipment, evaluation, and contingency planning. Air Mobility Command

(Provisional), pp. 6-9–6-10. Notes,

Wednesday Staff Meeting of Lt. Gen. Kross,

Provisional AMC Commander, Mar. 4, 1992.

AMC/HO. Tel. interview, Carroll

Bloomquist, Dec. 29, 1998. Col. Bloomquist

developed the AMC position and accompanied Johnson and Roadman to Washington.

71. Betty R. Kennedy, Background Paper,

subj: Evolution of Roles and Missions

Autho rities Vested in AMC and USTRANS -

COM, 1941–1994, Nov. 30, 1994, AMC/HO.

72. The UCP in effect “defines” the system of U.S. joint unified and specified commands, delineating the mission of each, as

well as the area of responsibility and the component commands that compose it.

73. Fogleman Oral History, pp. 22–23.

Some of the AMC staff believe that Gen.

McPeak was behind Fogleman’s initiative.

Hamilton tel. interview, Feb. 25, 2000.

74. The transfer of AMC C–130s was

effective Oct. 1, 1993. Betty R. Kennedy,

Background Paper, Subj. Evolution of Roles

and Missions Authorities Vested in

AMC/USTRANSCOM, 1941–1994, Nov. 8,

1996, AMC/HO. 

75. Interview, Brig. Gen. (Dr.) Thomas D.

Gensler, USAF, MC, USAF Medical Digest

44 (Fall 1993): 6. Dr. Gensler was the ACC

Command Surgeon and discusses the ACC

medical service including its forthcoming

assumption of the tactical AE mission. For

the success of his medical service, he stressed

the need for “a Total Quality (TQ) culture.”

76. Tel. interview, Col. Richard

Devereaux, USAF, Feb. 9, 1999. Col.

Devereaux, Chief of the Joint Staff J–3

(Operations) Readiness Division, at the time

of the interview, had a background in AMC

as a C–5 pilot and squadron commander. He

wrote a study while at the School of

Advanced Airpower Studies at the Air

University expressing concern that

DIRMOBFORs might be appointed without

airlift experience and would not have the

“clout” with the JFACC to ensure that the

JFACC understood the issues involved in his

airlift support. See Lt. Col. Richard T.

Devereaux, Theater Airlift Management and

Control: Should We Turn Back the Clock to

be Ready for Tomorrow? (Maxwell AFB,

Ala.: Air University Press, 1994). When

TRANS/AMC commander, Gen. Fogleman

sought to ensure the requisite expertise by

establishing the Air Mobility Warfare Center

at Fort Dix, N.J., for the Advanced Study of

Air Mobility (ASAM) which had as one of its

“core” courses a DIRMOBFOR seminar. I

am indebted to Ms. Ellen Galloway, secretary

to the ASAM dean of education, for a copy of

the descriptive brochure on ASAM and its

current class of 2000.

412

Notes
77. The chief of staff required AMC to

define “proponency” and was not pleased

with the command’s initial statement because

he did not think it expansive enough. McPeak

told the provisional AMC Commander, Gen.

Kross, who briefed him in the Pentagon in

April, that AMC’s proponency statement

“did not go far enough into requirements and

inventory/fleet management.” Memo for the

[USAF] Deputy. Chief of Staff, Plans and

Operations, from Col. Michael M. Dunn,

Subj. ACC/AMC Brief to CSAF, Apr. 30,

1992, AMO/HO

78. Position Paper on Fixed-Wing

Aeromedical Evacuation and Proponency.

Emphasis in the original. The paper’s origins

lay in a query from the new AMC Command

Surgeon, Gen. Hoffman, to his senior medical planner, Lt. Col. Mark Hamilton,

whether the AMC SG controlled the

aeromedical evacuation system. Hamilton

had succeeded Col. Bloomquist in the planner’s position. Hamilton tel. interview, Feb.

25, 2000. 

79. Ibid.

80. Ibid.

81. Ibid.

82. Ibid.

83. Ibid.

84. Ibid. Emphasis in the original.

85. The staff officer in question made this

assertion followed by the injunction in

extremely large type “Recentralization of the

Aeromedical Evacuation System is an

Imperative” in concluding Position Paper on

Fixed-Wing Aeromedical Evacuation and

Proponency. 

86. Ibid.

87. Joint Pub 4-02.2 was published Dec.

30, 1996. Joint publications were initiated

under the direction of the Chairman, JCS,

Gen. Colin Powell, in Nov. 1991, with the

publication of Joint Pub 1, Joint Warfare of

the Armed Forces (Fort Lesley J. McNair:

National Defense University Press, Nov. 11,

1991). According to participant Lt. Col.

(Ret.) Philip Mahlum, Joint Pub 4-02.2 was

developed at a joint drafting session held at

TRANSCOM headquarters under AMC SG

leadership and the draft took more than six

months to coordinate at the headquarters

level and to secure final approval. Tel. interview, Feb. 22, 2000.

88. Joint Tactics, Techniques, and

Procedures for Patient Movement in Joint

Operations, p. II-2.

89. For example, the interservice controversies of the late 1950s and 1960s about

which service, Army or Air Force, moved

casualties from forward echelons of care to

rear-area MTFs, were supplanted by the flexible approach used in Desert Storm that recognized the need to supplement integral service component commands’ AE capabilities

with support from other services as needed or

a joint AE common-user system. See Joint

Tactics, Techniques, and Procedures for

Patient Movement in Joint Operations, pp. II7–II-8. This joint publication as evidenced by

its number, Joint Pub 4-02.2, is a subset of the

basic joint doctrine publication regarding

medical support of joint operations published

the year before in whose drafting AMC had

participated. See Joint Pub 4-02, Doctrine for

Health Service Support of Joint Operations,

Apr. 26, 1995. A recent interview with Col.

Sarah Wright, the first flight nurse assigned

to the C–3 cell in the TACC who served from

June 1992 to Nov. 1995, indicates that the

system envisioned in Joint Pub 4-02.2 has not

yet been fully implemented. Tel. interview,

Col. (Ret.) Sarah Wright, NC, USAF, May

31, 2000.

Chapter Eleven

1. Memo, for Sgs at AMC, ACC, USAFE,

AFRES, ANGRC, TRANSCOM, CINCENT, and AMC TACC, et al., from Col.

Thomas A. Chester, MSC, USAF,

Commander 1st AES, Subj.: Aeromedical

Evacuation After Action Report–Operation

Restore Hope/Somalia, June 15, 1993. I am

indebted to Lt. Col. John Felins, MSC,

413

Notes
USAF, for a copy of this report, which he

drafted and copies of the Concept of

Operations for the Theater AE System

Briefing and pertinent extracts from CONOPLAN 1292 itself prepared for the Somalia

operation. The then Capt. Felins deployed to

Mogadishu with the main body of the 1st

AES in late December, 1992. He was the

Chief of the Theater Aeromedical Evacuation

Operations Policy Development and

Deployment Team that later prepared the

ACC general CONOPS for deploying and

operating theater AE systems after the 1st

AES transferred to ACC. Memo for HQ

USAF DO/SG, USTRANSCOM GPMRC,

AMC TACC, USACOM, HQ ACC, et al.,

Subj. ACC Concept of Operations

(CONOPS) for Theater Aeromedical

Evacuation System Assets, Gen. Thomas

Gensler, ACC Command Surgeon, February

28, 1995, AMC/HO.

2. The offer of 20,000 to 30,000 U.S.

troops to support relief operations in Somalia

was made on Nov. 26th by Acting Secretary

of State Lawrence Eagleberger, but the subsequent TACC query of the Pentagon

revealed that the Pentagon had no plans

underway for such an undertaking. Kent M.

Beck and Robert deV. Brunkow, Global

Reach in Action: The Air Mobility Command

and the Deployment to Somalia, Vol. I (Scott

AFB, Ill.: Office of History, AMC, Feb. 15,

1994), entry for Nov. 26, 1999, p. 26. Global

Reach is a chronological narrative of the

principal events of each day. However,

according to the then AMC

commander/CINCTRANS, Gen. Fogleman,

he had gotten a sense from conversations

with Chairman Powell that the United States

might get directly involved and had taken

steps to position mobility forces in anticipation of a possible U.S. deployment.

Fogleman Oral History, pp. 12–13.

3. Howell, tel. interview, Apr. 1, 1998.

After Action Report, Operation Restore

Hope/Somalia, p. 8.

4. Tel. interview, Lt. Col. Farley Howell,

NC, USAF, Apr. 1, 1998. Howell relates that

he was at Pope AFB when alerted to deploy

and got information about the new doctrine

regarding the AME via facsimile and which

he felt was not very clear. He subsequently

discussed his role with Lt. Col. Philip

Mahlum of the AMC Command Surgeon’s

office by telephone, but Mahlum could not

further clarify the AE liaison’s role in the

AME or Howell’s specific responsibilities in

the AME and recommended that Howell just

do the best he could. Howell’s characterization of the planning documents made available to the AE planners at Pope AFB is supported by the 1st AES commander’s afteraction report on Restore Hope, which stated

that these documents “were often contradictory in nature and failed to include mission

essential data and intelligence” (p. 12). It

should be noted that Howell’s departure

occurred only five days after the President’s

action, and the CONOPS was being hastily

prepared at CENTCOM HQ at MacDill

AFB, Fla., during that same short period.

Howell went directly to McGuire AFB from

Pope and was airlifted with other members of

the AME to Rhein-Main on a C–5 via Cairo

West, which was the primary refueling point

for airlift flowing from the United States to

the AOR. 

5. The quoted characterization is from

LTC (P) Iris J. West, NC, USA, and Maj.

Christopher Clark, NC, USA, “The Army

Nurse Corps and Operation Restore Hope,”

Military Medicine 160 (Apr. 1995): 179.

These authors drew upon more than ninety

oral history interviews with Army nurses

who served in Somalia who reported that

they were confined to the hospital compound

because of the chaos and danger outside,

which was quite unlike their Saudi Arabian

experience. They relate a case in point (pp.

181–82) of a young Irish nurse working with

one of the humanitarian operations in

Mogadishu who was killed by Somali bandits on her way with several colleagues to a

reception in the Somali capital.

414

Notes
6. A concise background on the U.S.

deployment to Somalia can be found in

Memo for Senator Thurmond and Senator

Nunn from Senator Warner and Senator

Levin, Subj.: Review of the Circumstances

Surrounding the Ranger Raid on October

3–4, 1993, in Mogadishu, Somalia, Sept. 29,

1995, published by U.S. Senate Committee

on the Armed Services. 

7. Ibid. The best work from a politicalmilitary policy perspective informed by their

roles in the crisis is John L. Hirsch and

Robert B. Oakley, Somalia and Operation

Restore Hope: Reflections on Peacemaking

and Peacekeeping (Washington, D.C.:

United States Institute of Peace, 1995).

Oakley was the former ambassador to

Somalia and Hirsch the former Deputy Chief

of Mission in Mogadishu. Oakley was called

upon by President Clinton to return to

Mogadishu to attempt to secure an agreement

with Mohammed Aidid following the

October Rangers raid that ended so disastrously. The book includes appendixes containing relevant UN Security Council resolutions and other appropriate documents.

8. Col. Thomas Chester, after-action

report of Operation Restore Hope/Somalia.

The report was actually written by Capt. John

Felins, who deployed to Somalia with the

main body of the squadron. He had commanded the Headquarters Squadron Section

of the 1611 AES for Col. Brannon during

Desert Shield/Desert Storm. Tel. interview,

Feb. 2, 1999. Also see the Warner–Levin

report cited previously. Mark Bowden’s

Black Hawk Down: A Story of Modern War

(New York: Atlantic Monthly Press, 1999),

an unofficial account based in part on interviews with both U.S. and Somali participants, won its author the Overseas Press

Club’s Best Foreign Reporting on the Battle

of Mogadishu award for The Philadel phia

Inquirer. However, Bowden does not relate

the key role played at the Mogadishu airport

by USAF AE personnel in the emergency

treatment of Ranger casualties that was suffered in conflict with Somalis in early

October 1993.

9. Chester, After-Action Report Operation

Restore Hope, p. 8. Howell tel. interview,

Mar. 24. 2000. North was appointed AFFOR

Surgeon upon arrival in Mogadishu; msg.,

AECC, Mogadishu [signed Howell] to HQ,

AMC (SGX), subj: Djibouti/Cairo West Trip

Report, Dec. 30, 1992, AMC/HO.

10. Ibid. Howell interview, Apr. 1, 1999.

Howell recalled the flight surgeon as both

eager and willing but understandably lacking

in experience with tactical aeromedical evacuation because he had been detached from

the Strategic Air Command to deploy to

Somalia.

11. Brannon’s 2d AES, now under command of the European theater commander,

was in the midst of shifting operations to

Ramstein Air Base as the U.S. forces in

Europe continued their drawdown, which

included the Air Force hospital at Wiesbaden

near Rhein-Main Air Base. The flight nurse

and medical technicians were Brannon’s personnel who had already shifted their place of

assignment.

12. Howell interview, Apr. 1, 1998. This

interim system focused on the USS Tripoli

had been described to the 37th AEG, AFRES,

from which the OIC of the AEOT to be

deployed to Cairo West was to be drawn, by

the AMC medical planner, prior to Howell’s

arrival in Mogadishu. Fax msg, Maj. Philip

Mahlum, AMC/SGX, to 37th AEG/SG,

Subj.: Somalia AMC Medical Support

CONOPS, Dec. 12, 1992. Colonel Hadbavny

was to become the DIRAEFOR at Cairo

West in late July 1993. I am indebted to

Colonel Eileen Hadbavny, NC, USAFR, for a

copy of this msg. Documents that I have used

from among those in her possession are hereinafter cited as Hadbavny papers.

13. The Samaritan missions began in

early January after patients had begun to

arrive at Mogadishu from outlying stations

without medical attendants. Msg., AECC

Somalia to TACC, Scott AFB, Subj:

415

Notes
MEDRED-C to Operation Restore Hope,

Jan. 5, 1993, AMC/HO.

14. Tel. interview, Major Edward Gruber,

NC, USAFR, Mar. 24, 2000. Maj. Gruber is

an Air Reserve Technician, assigned to the

AFRES 315th AES at Charleston AFB. Tel.

interview, Col. (Ret.) Walter Evans, USAF,

Mar. 29, 2000. Evans was the DIRMOBFOR

for Operation Restore Hope.

15. This individual seems to have been

the worst operational casualty during the

U.S.–controlled first phase of Restore Hope.

Several interviewees in discussing variations

in the usual Samaritan mission itineraries

mentioned the obviously same severely

injured victim of an accident involving an

overturned Army vehicle who had been

flown directly to Mogadishu and subsequently to Mombasa. The capabilities of the civilian medical facilities in Kenya are detailed in

Col. Robert L. Ditch, MSC, USAF, UNOSOM II End of Tour/Annual Medical

Operations Report, 4 May 1993–1 Jan 1994.

Col. Ditch served as the Chief Medical

Officer for UNOSOM II. I am indebted to

Col. Ditch for a copy of his report.

16. After-Action Report Operation

Restore Hope, p. 2. Intratheater airlift was

generally performed by C–130s, but New

Zealand C–748s that were equipped with litter brackets were occasionally also used

when it was impossible to generate a C–130

for an AE mission; Howell interview, Apr. 1,

1998. Tel. interview, Lt. Col. John Felins,

MSC, USAF, Feb. 2, 1999. Felins deployed

to Mogadishu with the 1st AES. Interview,

Col. Courtney Scott, MC, USAF, Feb. 24,

1998. Operation RESTORE HOPE Theater

AE System Briefing, [Dec. 4, 1992; date of

the briefing is cited in the After-action

report.] The definition of a stable patient is

from AMC Regulation 164-1, which cited a

definition promulgated by the JCS Medical

Steering Committee in 1985 for wartime

movements of patients. The AMC Regulation

is quoted in Thomas Chester, Aeromedical

Evacuation After Action Report, Exercise

KNIGHTLY ROGUE, June 1, 1994,

Attachment 6. I am indebted to Lt. Col.

Susan Konczal for a copy of this report.

17. Felins tel. interview, Feb. 2, 1999.

18. After-Action Report Operation

Restore Hope, p. 4. Felins tel. interview, Feb.

2, 1999. During the UNOSOM II period of

activity, refueling was carried out at

Mogadishu airport from fuel cells. However,

there was a restriction to the maximun aircraft on the ground (MOG) at one time of

four.

19. Gen. H. T. Johnson (see Chapter 9)

and Col. Evans both indicated in separate

interviews that Gen. McPeak wanted no Air

Force officer with the title of “commander”

other than the Air Force component commander deployed in accordance with his “one

boss” organizational philosophy. Tel. interview, Col. Evans, Mar. 28, 2000.

20. The issue of who controlled the strategic AE crews is discussed in Chester, AfterAction Report Operation Restore Hope, pp.

12–13. Indications of friction within the

deployed AE system reportedly caused Gen.

Roadman to dispatch messages to the AMC

AE elements in the field during Restore Hope

urging greater cooperation. Tel. interview,

Philip Mahlum, Mar. 29, 2000. The issue was

discussed at some length in an e-mail msg.

from Maj. Mahlum to the AEOT OIC, Col.

Ross, Subj. AE Intertheater AE Missions,

Jan. 25, 1993. Reading Message 15,

Hadbavny papers.

21. Given the relatively limited numbers

of medical flight crews available in the

Somalia operation, the ability to interchange

C–141 and C–130 crews was both useful and

necessary because the AECMs were volunteers from a variety of ANG and AFRES

units that had either tactical or strategic AE

missions. With regard to the difficulties in

mixing AECMs with tactical and strategic

backgrounds that Col. Brannon had experienced during Desert Shield, one of the flight

nurses with experience in the Gulf War indicated on the basis of her experience during

416

Notes
UNOSOM II that those sorts of difficulties

had been largely overcome. She pointed to

the fact that, during her active duty in the

AOR, strategic missions during Continue

Hope were flown by medical flight crews

with mixed tactical and strategic AE backgrounds. Tel. interview, Maj. Jill Von Rothe,

NC, USAFR, June 4, 2000. However, the

AECC chief at Cairo West during this period

with considerable experience as a flight nurse

exclusively on C–141s, at least initially, had a

less than sanguine view about the effectiveness of using mixed crews after observing

that C–130 qualified members knew nothing

about C–141s. Tel. interview, Lt. Col. Eileen

Hadbavny, NC, USAFR, June 7, 2000. Col.

Hadbavny was AECC chief and director of

AE forces at Cairo West from mid-July to

early November 1993. In her after-action

report, Col. Hadbavny did report that the

integration of the C–130 and C–141 crews on

a routine C–141 AE mission to Cairo

“seemed satisfactory,” but her judgment

came only after the C–130 qualified nurses

had received a review of the C–141s emergency exits and equipment prior to departure.

Col. Hadbavny also described tensions that

existed between the AECMs located in

Mogadishu and the AECC at Cairo West.

Although personality differences may have

played some role, the problem seems to have

had its roots in the different AE milieus,

strategic or tactical, from which she and tactically trained flight nurses came. Her associate reserve unit at Charleston flew regular

intertheater (or strategic) missions, which

meant that she was intimately familiar with

USAF-prescribed ways of conducting missions and documenting them. In 1993, the

live movement of patients was not something

routinely done by ARC AE personnel who

many times had more years of experience

with clinic aspects of in-flight care aboard

specific airlift aircraft than did active duty AE

personnel who usually had only one assignment as AECMs but less direct experience

with the worldwide AE system. She records

that, when the OIC of the MASF at

Mogadishu changed, a previously cooperative relationship diminished “and one of distrust of the Cairo ‘establishment’ occurred.”

Lt. Col. Eileen S. Hadbavny, USAF

Aeromedical Operations for Operation

Restore Hope/Continue Hope–Somalia, 19

July to 8 November 1993. June 13, 1994, p.

16. I am indebted to Col. Hadbavny for a

copy of her after-action report. One of the

medical technicians in a recent interview also

attributed what were readily apparent differences in perspective between the OIC of the

crews on alert at Mogadishu and the AECC

chief in Cairo to the fact that the former came

from a tactical AE background and Col.

Hadbavny from a strategic AE background.

Brown tel. interview, June 7, 2000.

22. As early as Dec. 31, C–9s were being

deployed to Cairo to meet retrograde AE missions originating in Mogadishu. Msg. AECC

to TACC, Scott AFB, et al., subj: MEDREDC to Operation Restore Hope, Dec. 31, 1992.

AMC/HO.

23. After Action Report Operation

Restore Hope, p. 4. Howell interview, Apr. 1,

1998.

24. Gruber tel. interview, Mar. 24, 2000.

25. Staff Summary Sheet (SSS), CINCTRANS/AMCCC from Gen. Roadman, subj:

Enhanced Aeromedical Evacuation

Communication/Automation Demonstration

in Support of Operation Restore Hope, Dec.

12, 1992. AMC/HO. Roadman annotated the

original SSS by writing in ink that the proposal had been coordinated with CENTCOM

and the JCS who all supported the initiative.

He added a fragmentary comment: “a necessary test for our future capability.”

26. Ibid. According to 1st AES personnel

who were in Mogadishu, the notebooks

proved to be of very limited value because

the dusty conditions soon made them inoperative. However, the PACER BOUNCE communications system continued to have a limited manual data-transmission capability. The

keyboard for the data input device was so

417

Notes
small that it was difficult to use, and the transmission system tended to “freeze” if large

amounts of data were imputed. Tel. interviews, Col. Farley Howell and Lt. Col. John

Felins, respectively, Mar. 24 and Mar. 23,

2000. Tel. interview, Maj. Edward Gruber,

NC, USAF, Mar. 24, 2000. Maj. Gruber

served in Mogadishu during Somalia operations. Tel. interview, Col. (Ret.) Sarah

Wright, NC, USAF, May 31, 2000. Col.

Wright directed the AE cell in the TACC at

AMC HQ during the Somalia operations, and

was the point of contact for AE requests originating in the AOR. Msg, AECC to TACC,

Scott AFB, Subj: MEDRED-C Operation

Restore Hope, Dec. 29, 1992. Personal computers with data modems were widely used in

the Gulf AOR to communicate directly with

CONUS-based facilities. This largely unanticipated usage tended to cause performance

problems in the common user communications systems used by the U.S. forces in the

AOR. L. K. Wentz, C. H. Harris, et al.,

Perspectives on C3I Performance in Desert

Shield/Desert Storm, Annex H: Communi -

cations (McLean, Va.: The MITRE Corpora -

tion, Oct. 1991), pp. 38–39.

27. Col. A. Felix Meyer III, 24th Medical

Group after-action report: Operation Just

Cause’, copy n.d. I am indebted to Col. Meyer

for a copy of this report. Col. Meyer is a former commander of the 24th who was one of

the primary planners for that operation. 21st

AF/LGM to 437 LSS, Charleston AFB/LG,

Info: HQ AMC/LGA, HQ AMC/TACC, HQ

22AF/LGM, HQ 60 AW/LG, et al., Subj:

Request for One Time Inspection, Dec. 4,

1992. AMC/HO. The 437th Wing Comman -

der, Brig. Gen. Mikolacjik, deployed to

Somalia as the AFFOR.

28. Msg, 21st LGM to 437 LSS, Subj.:

Request for One Time Inspection.

29. After Action Report Operation

Restore Hope, p. 2. The need for an AELT

presence on Navy ships that received substantial numbers of casualties had first

emerged nine years earlier during Urgent

Fury, the invasion of Grenada. Based on his

experiences trying to coordinate patient

movement from the U.S. aircraft carrier, USS

Independence, the then 1st AES Commander,

Lt. Col. Felix Meyer, had concluded that

there was no good convenient way of interfacing with the Navy and indicated he would

advocate placing at least one AELT member

on such vessels in future contingencies.

Remarks to the 91st Annual Meeting of the

Association of Military Surgeons of the

United States [1984]. I am indebted to Col.

Meyer for a transcript of his remarks.

30. After Action Report Operation

Restore Hope, pp. 4–6. Howell interview,

Apr. 1, 1998. A prior attempt to deploy an

Army hospital to Mogadishu by ship was

unsuccessful for reasons that apparently

involved the draft of the vessel and the shallow water off the coast of the capital. Tel.

interviews, Lt. Col. John Felins, Mar. 22,

2000, and Col. Farley Howell, Mar. 24, 2000.

Msg., AECC to TACC, Subj: MEDRED-C to

Operation Restore Hope, Jan. 5, 1992.

AMC/HO. The first intertheater AE mission

that was staged directly from the 86th Evac.

Hospital was launched on Jan. 14, 1993, and

was judged to be a success, which bolstered

the planned redeployment of the MASF.

Msg., AECC to TACC, Subj: MEDRED-C to

Operation Restore Hope, Jan. 14, 1993. In

late Feb., the AMC/SG planners feared that

the TACC was going to establish a force rotation policy of 179 days, which strengthened

their desire to fill ongoing AE taskings with

ARC personnel rather than use those from

the 1st AES because of continuing support

requirements elsewhere including potential

requirements “for Yugoslavia support.” Maj.

Philip Mahlum, Point Paper, Subj.: Somalia

Force Requirements Post-Rotation, Feb. 25,

1993. Hadbavny papers. This point paper

was faxed to the AEOT OIC the same day.

31. The Djibouti refueling stop was eliminated after fuel cells were set up at the

Mogadishu airport.

32. Major Howell and a survey party flew

418

Notes
to Djibouti shortly after the arrival of the 1st’s

main body in the AOR to evaluate the medical facilities available in the former French

possession. The French hospital, the Centre

Hospitalier des Armees “Bouffard,” located

fifteen minutes from the Djibouti airport was

deemed “ideal” by the survey team for emergency treatment of AE evacuation patients

and as an emergency patient holding facility.

It also had an INMARSAT terminal that

would allow it to communicate with the U.S.

Army hospital at Mogadishu. Msgs., AECC

to TACC, Subj.: MEDRED-C to Operation

Restore Hope, Dec. 20, 1992 and Jan. 5,

1993. AMC/HO. Felins tel. interview, Mar.

22, 2000. A complete description of the

“Bouffard” Hospital’s medical capabilities

can be found in the UN Chief Medical

Officer’s (CMO) after-action report, III.6.

See Major Robert L. Ditch’s UNOSOM II

End of Tour/Annual Medical Operations

Report.

33. After Action Report Operation

Restore Hope, p. 2.

34. Memo for AEOT [Cairo West] from

Maj. Farley J. Howell, Director, AE Forces

(DIRAEFOR) [Mogadishu], Subj.: AECC

Relocation, Feb. 23, 1993. Hadbavny papers.

Howell had replaced Col. Chester as DIRAEFOR upon the latter’s departure. He made an

oblique reference to the conflict between the

AEOT OIC, Lt. Col. Ross, and the AECC in

Mogadishu by noting as one of the advantages of his proposal that “absorbing AE

coordination functions into the Cairo

Operation will eliminate any confusion over

mission responsibility.” This comment

undoubtedly helped commend his proposal

to Col. Ross with whom Howell had initially

had disagreements on precisely that issue.

Howell tel. interview, Apr. 1, 1999.

35. Howell memo for AEOT, Feb. 23,

1993.

36. Ibid. General Fogleman told his staff

in late December that he expected Restore

Hope airlift to begin tapering off about Jan. 7

because the first redeployment mission was

set for Jan. 2. He expected the first marines to

follow by Jan. 20, and foresaw a move

toward a UN force, possibly within a month,

with further withdrawals of Americans leaving only a small number to supply command

and control and as staff officers for the UN

peacekeeping force. Kent M. Beck and

Robert deV. Brunkow, Global Reach in

Action: The Air Mobility Command and the

Deployment to Somalia (Scott AFB, Ill.:

AMC Office of History, Feb. 125, 1994), p.

107. Global Reach is a chronology that lists

by day relevant information drawn from situation reports and other messages from the

field, memoranda, notes of meetings (particularly with Gen. Fogleman), and pertinent

information from outside sources that are relevant to the situation.

37. Chester, After Action Report

Operation Restore Hope, p. 2. Howell interview, Apr.1, 1998.

38. The initial MASF manning was 6

flight nurses and 19 AE medical technicians

who were equipped with cardiac monitors,

ventilators, pulse oximeters, infusion pumps,

oxygen analyzers and oxygen suction

devices. Their mission was to hold, process,

and provide nursing care for at a maximum

of 25 patients for up to 6 hours. In his report,

the UN Chief Medical Officer during UNOSOM II, Maj. Robert Ditch, says that he

requested reactivation of the MASF and the

deployment forward of additional medical

flight crews following the hostile incidents in

early June. UNOSOM II End of Tour/Annual

Medical Operations Report, 4 May 1993 – 1

Jan 1994 (Mogadishu, Somalia: Office of the

Force Medical Staff, 1 Feb. 1994), pp. 37–39,

47. The CENTCOM Surgeon’s office had

requested even earlier on Apr. 9th that the

MASF be reactivated to provide holding

facilities at the airport after the 86th to the

embassy site. This was apparently done

because in late May, the AECC, now located

at Cairo West, proposed that the MASF in

Mogadishu be eliminated in the interest of

further reducing AE forces in Somalia. Still,

419

Notes
the MASF tentage was reportedly left in

place to “back” the ambulance to aircraft

transfers that were the norm until early June.

Msg., USCINCENT/CCSG, to USCENTAF,

Shaw AFB, SC/SGX, Subj.: MASF Request

in Support of Restore Hope, Apr. 9, 1993;

msg., AECC, Cairo West, to HQ AMC/

SGXP, Subj.: Downsizing A/E Forces in the

AOR, May 12, 1993. AMC/HO. Ltr, Lt. Col.

Konczal to the author, May 24, 2000. Gruber

tel. interview, Mar. 24, 2000. The 86th was

replaced by the 42nd Combat Support

Hospital (CASH) in April which was, in turn,

replaced by the 46th CASH in August.

39. West and Clark, “The Army Nurse

Corps and Operation Restore Hope,” p. 180.

Gruber tel. interview, Mar. 24, 2000.

Flossman interview, Dec. 12, 1998. 

40. AMC Public Affairs Office, Restore

Hope Statistics. AMC/HO. Chester, AfterAction Report Operation Restore Hope, p.6.

Ditch, UNOSOM II End of Tour/Annual

Medical Operations Report, p. 49.

41. Tel. interview, Col. (Ret.) Walter

Evans, USAF, Mar. 28, 2000. Evans had

been Mikolacjik’s operations officer when

Mikolacjik had commanded the 435th Airlift

Wing at Rhein-Main, and they had earlier

served together as majors on the AMC staff

and on the Air Force C-X task force that was

created to designate the specifications for

what was to become the C–17. Mikolacjik

was also designated Deputy Air Component

Commander under a USMC general officer.

42. One discordant note was that sounded

by Lt. Col. Flossman, AECC chief during the

latter part of 1993 and commander of the

ANG 142 AES, who said later that he came

away from the Somalia operations with the

strong feeling that ninety-day tours of duty

for ANG medical flight crews in small-scale

operations like peacekeeping stretched the

tolerance of the employers of ANG AE crew

members unnecessarily because he believed

that the AF could secure enough ANG volunteers for two-week rotations. The record does

reveal that AMC was sensitive to the problems of ARC personnel having trouble with

their civilian employers if they were held too

long on active duty. Volunteer aircrew had

been integrated into the airlift supplementing

active duty flight crews, and, as early as Dec.

18, AMC advised its subordinate headquarters that scheduled return times for the latter

would be extended as necessary but that

AMC wanted to honor ARC crew scheduled

return dates because “volunteer crewman had

civilian job commitments.” The underlying

factor was AMC’s desire to maintain a sufficient number of ARC volunteers to provide

some possible relief for the active duty crews

during the then coming holidays, and the

Mobility Command headquarters did not

believe that that could be achieved without

some reasonable assurances that ARC members would be returned to civilian life as

scheduled. Global Reach in Action, p. 67.

43. For example, Jill Von Rothe, the flight

nurse who voluntarily and successfully took

over the task of creating a medical logistics

system for Brannon during Desert

Shield/Desert Storm, served as one of the alert

medical flight crew members rotating between

Cairo West and Mogadishu every two weeks

during May and July 1993. Tel. interview,

Maj. Jill Von Rothe, NC, USAFR, June 4,

2000. Tel. interviews, Lt. Col. Susan Konczal,

MSC, USAFR, May 17 & 18, 2000. Konczal

had volunteered for a 120-day active duty tour

from her MacDill AFB unit, the 37th AES

AFRES. Ltr, Col. Ditch, MSC, USAF, to the

author, May 4, 2000. In a few cases, at least at

the beginning of AE system operations, prior

association had apparently not made the heart

grow fonder. Tel. interview, Col. Farley

Howell, NC, USAF, May 10, 1999. Ditch

reports that he continually warned UN headquarters of the problems posed by the lack of

a UNOSOM medevac capability which forced

him to rely on medevac helicopters owned by

the national contingents and UNOSOM contract aircraft. However, the UN never took

action to provide any. Ditch, UNOSOM II End

of Tour Report, p. 43.

420

Notes
44. Allowable flight crew duty was

increased successively from 125 hours per

month to 150 hours and finally to 165 hours

during ANC’s “surge operations,” Dec. 9

1992 to Jan. 11, 1993. Halfway through that

period, the TACC also authorized wing commanders to issue waivers to allow C–5 and

C–141 pilots who were being grounded for

pending retirement or promotion to continue

flying. An early release program for C–130

pilots and navigators was also suspended in

early January as the effect of voluntary separations and reductions in force programs

began to take effect on efforts to support

Somalia and other commitments. Although

the airlift activity in terms of missions and

tons transported during Restore Hope was

substantially less than that during Desert

Shield in August 1990, a number of factors

hampered operations for airlift support of

U.S. deployments to Somalia. Not the least of

these were constraints on the airlift system

imposed by restrictions on the operation of

the C–141 fleet (discussed later) and the limited number of suitable airfields and the

absence of supporting infrastructure in

Somalia; one observer described the situation

as trying to force a large amount of material

through a funnel the wrong way. These things

helped create periodic disruptions of the flow

plan that caused flight crews and aircraft to

spend longer times away from their stations

than planned. The aging airlift fleet contributed to interruptions in the flow plan

through aircraft breakdowns, which also

interrupted the flow plan. Global Reach in

Action, pp. 66, 71, 95, and 122.

45. The conflict over the issue of who

controlled the strategic AE crews seems to

have been confined to the Restore Hope period, and was, according to observers, rooted

more in personality differences than in doctrinal ambiguity, even though there was an

obvious issue of the respective authority of

the two elements. Howell tel. interview, May

10, 1999. Mahlum tel. interview, June 14,

2000. 

46. The UN paid for the deployment of

the U.S. Army hospitals, the 42d and 46th

Combat Support Hospitals, which operated

successively in Mogadishu during UNOSOM II. This gave Ditch as UN Chief

Medical Officer directive authority over the

hospitals, but the latter governed themselves

according to terms of reference (TOR)

which, to Ditch’s frustration (particularly

because the UN had never agreed to the

TOR), restricted their medical support to U.S.

personnel only. They would and did treat

other coalition personnel in an emergency on

a space-available basis. Ditch did have some

control over a number of UN-funded U.S.

MEDEVAC helicopters that he used together

with several French and German helicopters

to move patients intratheater. However, the

same limiting TOR applied to what he could

officially task this U.S. rotary-wing medevac

capability to do. His medevac system also

used fixed-wing opportune aircraft owned by

several national contingents and some UNcontracted, Russian-built Mi–17 helicopters

without medical equipment or medical crew

members. These aircraft could be configured

to take up to twelve litter or twenty-two

ambulatory patients, but were also limited in

their utility for medevac because of operational restrictions placed upon their employment, possibly because of insurance. UNOSOM II after-action report, pp. 43–48.

The term “TACON” to characterize the

relationship of the UN CMO to the aeromedical evacuation elements in Mogadishu during UNOSOM II was made in separate interviews by both an AELT OIC and an AECC

chief who were assigned to the Mogadishu

airport during the last half of 1993. Flossman

tel. interview, May 23, 2000; Konczal tel.

interview, May 17, 2000. Ditch himself

agreed in a subsequent interview that this was

probably a reasonable characterization of the

relationship. Tel. interview, Col. Robert

Ditch, MSC, USAF, June 12, 2000. The

OICs of the MASF and AELT did attend the

UN Medical Staff Meetings as did the Flight

421

Notes
Surgeon beginning in August, 1993.

Hadbavny After Action Report, p. 3.

47. Maj. Von Rothe was a member of a

U.S. medical flight crew that flew thirty-nine

Pakistani casualties to Islamabad on June 8,

1993. She also stood alert with the Italian

helicopter crews. On the AE mission to

Islamabad, the USAF AECMs, eight flight

nurses and eight medical technicians, had

minimal Pakistani assistance, including two

Pakistani interpreters, according to Von

Rothe. However, the report to the AMC

Surgeon on this mission indicated that there

had been a Pakistani physician and two medical technicians on board. Maj. Von Rothe

reports that, upon arriving in Pakistan, the

U.S. AECMs were not allowed to carry the

litters off the aircraft for reasons that were

never explained. Sgt. Clarence Brown, a

USAFR medical technician who also served

in the AOR during the summer of 1993, also

participated in such missions. Tel. interview,

June 4, 2000. Von Rothe tel. interview, June

4, 2000. Maj. David Bramigk, Point Paper,

Subj.: Aeromedical Evacuation of Pakistani

Casualties, June 8, 1993. AMC/HO. 

48. UNOSOM II After Action/End of

Tour Report, p. 46. The U.S. Army medevac

unit formally came under the command of

the commander of the 46th CASH. However,

sometimes his medevac helicopters were

commandeered for non-medevac purposes

by those higher up in the U.S. forces’ chain of

command, which caused the hospital commander concern about his readiness. Tel.

interview, Dr. Bruce Bailey, June 27, 2000.

49. In Djibouti, the French maintained

one medical evacuation crew comprising a

single physician and two nurses with four

C–160 cargo aircraft to move patients from

their base area in Somalia to the French military hospital in Djibouti. Repatriation of

patients from there was accomplished by

medical crews and aircraft from France. The

Italians maintained one physician/medical

technician team in Mogadishu primarily for

Huey support but which also could be used to

support patients on flights to Egypt where

Italian Air Force C–130s or jets could then

forward the patients on to Italy. The Germans

also maintained one AE team in Djibouti

with four C–160 aircraft, and Belgian forces

maintained one AE team in Mombasa with

their one mission support C–130. UNOSOM

II After Action/End of Tour Report, p. 47.

50. Ibid., p. 48. In his attempts to develop

a much-needed UNOSOM medical evacuation capability, Ditch apparently sought to

secure de jure TACON over some of the U.S.

AE resources in mid-August after the failure

of talks with German officials. He proposed

to create a combined fixed- and rotary-wing

support structure under his control manned

by six to seven flight nurses and a like number of medical technicians with a U.S. field

grade flight nurse to act as the coordinator for

the UNOSOM evacuation operations. The

AECMS would be distributed at three or four

in-country sites where non-U.S. UNOSOM

II forces were bedded down. Whereas the

correspondence on this matter reveals that

CENTAF recognized the need for flexibility

with regard to medical evacuation, it was

decidedly cool to the idea of Ditch having

direct tasking authority over U.S. AE forces.

Fax to Lt. Col. Hadbavny/Lt. Julie Glover

from Maj. Philip Mahlum, HQ, AMC/SGXP,

Sept. 2, 1993; msg, Mahlum to USCINCENT/CCSG, USCENTAF/SXM, and

AMC/SG, Subj.: UNOSOM II AE Support,

Sept. 2, 1993; msg., to Mahlum from Maj.

Weltz, 9AF/SGM (Medical Plans), Subj.:

UNISOM (sic) II AE Support, Sept. 2, 1993.

I am indebted to Col. Hadbavny for copies of

these documents. Other documents provided

by Col. Hadbavny are referred to hereinafter

as Hadbavny documents. 

51. Ibid., pp. 32–34. When the UN medical director from UN HQ, New York, visited

Somalia in May 1993, she neither knew who

the UN CMO was nor tried to contact him.

Ditch learned of her presence only by accident after she had been in Somalia a week,

and when he sought her out, he had only a 45-

422

Notes
minute discussion with her before she had to

leave. However, she sponsored Ditch’s visit

to UN HQ two months later and, according to

Ditch, spent a great deal of time with him

assisting him in becoming oriented to UN

procedures and policies. By all accounts of

those who have worked with Ditch, his

aggressiveness and dedication made him

exactly the right man to meet the challenges

of creating a health support system for UNOSOM II, an opinion shared by the author on

the basis of several contacts and a close reading of his after-action report.

52. The author participated in and helped

plan several such workshops conducted by

the Institute for National Strategic Studies

(INSS) of the National Defense University

while he was on the INSS staff. For example,

Dr. William H. Lewis, ed. The Security Roles

of the United Nations: Proceedings of a

Conference, October 9 & 10, 1991 (Fort

Lesley J. McNair: NDU Press, n.d.) and Dr.

William H. Lewis and Dr. Thomas A. Julian,

eds., Military Implications of United Nations

Peacekeeping Operations. Proceedings of the

Workshop, November 17, 1992 (Fort Lesley

J. McNair: NDU Press, n.d.). Also see Brig.

Gen. Raymond E. Bell, Jr. “Somalia

Revisited: Creating the Proper U.S. Army

Force Structure for Peace-Enforcement

Missions,” Armed Forces Journal (March

1997): 42–43.

53. Ditch, p. 91. As noted earlier, the

USAF had provided airlift support to UN

peacekeeping operations including patient

movement in the Congo many decades

before, but, in keeping with the unstated principle of the time regarding the principal

antagonists in the Cold War, no U.S. forces

were directly involved.

54. Tel. interview, Lt. Col. (Ret.) Philip Mah -

lum, MSC, USAF, Aug. 23, 2000. Col. Mahlum

was assigned to the GPMRC at that time.

55. Col. Howell notes on several occasions that requests by AECC to use a specific C–141 physically located in sight of AE

personnel on the parking ramp at Mogadishu

to evacuate a patient elicited the response that

the aircraft could not be there because its

presence did not match the TACC airlift flow

schedule. Howell tel. interview, Apr.1, 1998.

56. Tel. interview, Col. (Ret.) Sarah

Wright, NC, USAF, May 31, 2000. Lt. Col.

Eileen Hadbavny, who was the director of AE

forces during the period July 19–November

8, 2000, headquartered at Cairo West, said in

a recent interview that Cairo West appeared

to be in a communications “dead zone” during her tenure some of the time. Interview, Lt.

Col. Hadbavny, NC, ANG, June 29, 2000. 

57. Tel. interview, Lt. Col. Susan

Konczal, MSC, USAFR, May 18, 2000. The

then Maj. Susan Konczal was the officer in

charge (OIC) of the AELT, and she deliberately bypassed the AECC at Cairo West to

talk directly to Lt. Col. Wright in the TACC

and give the center a “heads up” with the

objective of pushing the AE system to secure

the required airlift as rapidly as possible. A

similar “heads up” was given the TACC

when Pakistani troops were attacked with

significant casualties in early June. Within a

few hours of that attack on June 5, 1993, the

TACC was notified of the possible regulation

of fifteen to twenty casualties, and was able

to identify an airframe and move three

“urgent” litter patients on the same day from

Mogadishu to Ramstein who had been regulated to the Landstuhl Army Hospital. Staff

Summary Sheet (SSS) with attached Point

Paper, Brig. Gen. Roadman for TACC/CC,

Subj.: Aeromedical Evacuation of Pakistani

Casualties, Jun. 8, 1993. The SSS has been

annotated by the AMC command surgeon in

pen with two points: “This contains a series

of great examples of Global Reach outlined

by TACC interface with staff,” and “We have

unbelievable capability!” AMC/HO. As indicated earlier, Col. Wright reported in her

recent interview that her communications

with Mogadishu were always better than with

Cairo West. Tel. interview, May 31, 2000.

58. Chester, After Action Report

Operation Restore Hope, pp. 18–21.

423

Notes
However, part of the problem Chester experienced with the DSN was competition for the

limited number of DSN lines available, a factor that he mentions briefly in his after-action

report. The AEOT com munications problems were also in part the result of poor radio

operator training and the failure to deploy

with cables necessary to operate a so-called

automatic link establishment (ALE), which

had been found to increase the reliability of

the PACER BOUNCE radios. 

59. Ltr to the author, Lt. Col. Susan

Konczal, MSC, USAFR, May 23, 2000. Col.

Konczal also stated in a recent interview that,

in spite of the variety of communications systems that were available for coordinating AE

missions, communications were always a

problem. Tel. interview, May 22, 2000. The

chief of the AECC during the later stages of

UNOSOM II also indicated his difficulties

with communications. Tel. interview, Col.

Loren Flossman, MSC, ANG, May 23, 2000.

The chief of the AE cell in the TACC

throughout the Somalia operations, Col.

Sarah Wright, noted in a recent interview that

it was easier to talk with Mogadishu than

with the AEOT at Cairo West. Konczal’s

means of communication with the TACC

was by DSN. The tactical airlift control elements (TALCE) in Mogadishu and at Cairo

West did have UHF SATCOM terminals. Tel.

interview, Wright, May 31, 2000. Tel. interview, Lt. Col. Eileen Hadbavny, NC,

USAFR, June 7, 2000. Lt. Col. Felins, the

then 1st AES Director of Operations for the

AECC at Mogadishu, confirmed that the

UHF SATCOM terminals that the 1st AES

brought to the AOR were redeployed with the

squadron when it returned to Pope in the

closing days of Operation Restore Hope. Tel.

interview, Lt. Col. John Felins, MSC, USAF,

June 4, 2000.

60. The shortage of C–141s also necessitated looking for other sources of airlift capability, and the AMC turned to substituting the

airlift capacity of KC–135s and KC–10s

when possible. As early as Dec. 10, Gen.

Fogleman had urged the use of the tankers’

airlift capability, telling his planners to “break

the mindset on KC–10s.” On Dec. 18, 1992,

the AMC vice commander, Gen. Walter

Kross, reported that, due to the shortage of

C–141 aircraft and crews, KC–10s were

being substituted for C–141 missions to

maintain the airlift flow. The C–141 fleet had

been operating under restrictions on its load

limit since the Persian Gulf War because of

cracks in the wing structure and around the

cockpit windows. However, in early May

1993, cracks were found in the aircraft’s wing

structures that resulted in a further reduction

of the load limit until the fleet had been

inspected. Finally, an analysis of the resultant

findings caused Gen. Fogleman to restrict 45

of the C–141B Starlifters from flight and 116

of the remaining 204 from any in-flight refueling. B. Opall, “USAF Restricts C–141s

After Report Notes More Cracks,” Defense

News (May 24–30, 1993): 5. AMC Press

Release 93-08006, “AMC Restricts Portion

of C–141 Fleet From Flight,” Aug. 9, 1993.

History of AMC, 1 June 1992–31 December

1994 (Scott AFB, Ill.: AMC History Office,

July 1995), 374.

61. Once decided upon, the KC–10 was

configured and launched within an hour and

a half with three litter and thirteen ambulatory patients. Air Mobility Warfare Center,

CTF–Somalia AFFOR/AME Lessons

Learned, n.d., pp. 4–5. AMC/HO. One of the

litter patients was a member of the Merchant

Marine with acid burns to both eyes. A second was a marine who had been sprayed by

the venom of a spitting cobra. Both had

injuries so severe that they could not wait for

a retrograde mission on an aircraft in the normal flow or diversion of a C–141. Global

Reach in Action, p. 131. The DIRAEFOR,

Lt. Col. Hadbavny, directed experiments that

revealed that catering trucks with extendable

ramps could elevate litter patients to door #6

which gave access to the C–5’s 75-place passenger compartment located high above the

cargo compartment. Hadbavny, USAF

424

Notes
Aeromedical Operations for Operation

Restore/Continue Hope–Somalia, 19 June to

8 November 1993 [hereinafter referred to as

Hadbavny after-action report], p. 25.

Hadbavny documents. The experiments were

described in detail to AMC/SGX including

various configurations of ambulatory and litter patients who could be carried. Memo to

AMC/SGX from Director of AE Forces

[Hadbavny], Subj.: Limited Litter Onload

Capabilities of C–5, Oct. 22, 1993.

Hadbavny documents. Hadbavny tel. interview, June 7, 2000. Almost as many KC–135

airlift missions (324) as C–141 missions

(411) were flown in support of Continued

Hope, the USAF support operation for UNOSOM II, between May 5, 1993, and Mar. 13,

1994. AMC/Public Affairs Fact Sheet,

RESTORE HOPE Statistics, Mar. 22, 1994.

AMC/HO.

62. Tel. interview, Wright, May 31, 2000.

63. Hadbavny after-action report, p. 11.

The “normal” C–141 alert crew was one

flight nurse and two medical technicians. I

am indebted to Col. Hadbavny for a copy of

her report. [1st AES], Operation Restore

Hope After-Action Briefing, n.d. I am indebted to Lt. Col. John Felins, who was director

of operations for the 1st AES in Somalia for

a copy of this briefing. Tel. interview,

Konczal, May 18, 2000. Tel. interview,

Martello, June 8, 2000.

64. Appendices 3 to Annex D to UNOSOM II OPLAN. Medical Services, dated

May 1, 1993, and Dec. 31, 1993, respectively, included in Ditch’s after-action report.

Memo for HQ AMC/SGX from 1610

ALSGP.AMED [Hadbavny], Subj.: AE

Manning Requirements for Operation

Restore Hope, Oct. 25, 1993. Hadbavny

papers.

65. Tel. interview, Konczal, May 18,

2000. Tel. interview, Von Rothe, June 4,

2000. Maj. Von Rothe indicated that an anesthetist from the 42 CASH accompanied the

Pakistani patients on the AE mission to

Islamabad by C–141 in June on which she

served as a member of the medical flight

crew. Tel. interview, Dr. Gordon Moshman,

USNR. Tel. interview, July 8, 2000. Dr.

Moshman had been deployed at Mombasa

for surveillance purposes with a specially

equipped E–3A from his parent patrol wing

at Brunswick, Maine. When he heard of the

Ranger casualties at Mogadishu, he secured a

flight that arrived at the Mogadishu airport at

dawn where for several hours he helped prepare patients for AE as they arrived from the

46th CASH. He served as an attending physician on the second of the C–141 aircraft dispatched to evacuate the wounded Rangers,

which departed at three on Tuesday afternoon

for a nonstop flight to Germany. It transported thirty-two patients: fifteen ambulatory,

seventeen litter including two on ventilators,

one of whom had been shot through the liver.

Moshman’s C–141 was diverted from

Ramstein to Rhein-Main where the patients

were transferred to a C–9 and flown to

Ramstein and then transported by ambulance

to Landstuhl Army Medical Center with

Moshman in attendance throughout the evacuation. Although without orders or personal

baggage, Moshman secured a C–141 flight

back to Mogadishu via Cairo West, and he

remained in the Somali capital until early

November. Ltr, Moshman to the author, July

30, 2000.

66. Memo for HQ AMC/SGXP from Lt.

Col. Hadbavny, Director, AE, Subj.: AE

Support for US Forces Somalia, Oct. 13,

1993. Hadbavny papers. The issue of attendants on AE flights was not a new concern

for the Army hospital staff. Dr. MacNamara,

who himself had been an Army special forces

medical officer, recalls having a discussion

with the 46th CASH commander, Dr. Bailey,

regarding the issue of an attendant whom the

CASH commander felt they could not supply

without compromising their medical mission

but whom MacNamara knew the Air Force

would require. He ended up sending an Air

Force medical technician as an attendant. Tel.

interview, July 24, 2000. Dr. ‘Moshman’s air425

Notes
craft was diverted to Rhein-Main Air Base at

Frankfurt because of a temporary closure of

the runway at Ramstein.

67. Col. Thomas A. Chester, pp. 9, 15–16.

Other observers have echoed this complaint,

in part, because of difficulties in using the

data-input devices provided for transmitting

data over the HF PACER BOUNCE radios as

well as problems with these radios’ ability to

transmit large amounts of data without shutting down the data flow (characterized as

“freezing” by one frustrated system user).

Tel. interview, Konczal, May 18, 2000. Tel.

interview, Wright, May 31, 2000.

68. Tel. interview, Lt. Col. Eileen

Hadbavny, NC, USAF, June 12, 2000.

Interview, Col. Hadbavny, June 29, 2000.

Hadbavny after-action report, pp. 8–10.

69. Information on SOC forces is generally highly classified. However, Collins has

drawn upon various unclassified testimony

by Gen. Stiner when CINCSOC which identified the Delta Force and Navy Seal Team 6

as permanently assigned SMU. Black Hawk

Down also mentions Air Force participants.

Delta Force includes personnel from all three

Services. John M. Collins, Special

Operations Forces (Washington, D.C.: NDU

Press, 1994), provides a concise description

of special operations forces, their organization, and command and control systems.

Special Mission Units (SMUs) include Army

Delta Force and Navy SEAL Team Six.

70. Tel. interview, Konczal, June 13,

2000.

71. For example, the NCOIC of the

MASF, TSgt. William Wise, ANG, was a

paramedic in civilian life with training in

ATLS and ACLS. The flight surgeon, Lt. Col.

MacNamara had been an infantry officer as

well as a special forces medic prior to entering the Air Force. Tel. interviews, July 9 and

June 6, 2000, respectively. Tel. interview,

MacNamara, June 12, 2000. Interview,

MacNamara, July 19, 2000.

72. Tel. interview, Maj. (Ret.) Rob Marsh,

MC, USA. June 28, 2000. MacNamara had

taught special forces medical technicians at

the John F. Kennedy School at Fort Bragg,

some of whom were assigned to the JSOTF.

He and Volpe had succeeded each other in

assignments with the U.S. personnel providing a “buffer” between Egypt and Israel in the

Sinai peninsula and were close personally.

Marsh and MacNamara had served together

years before. Tel. interview, Lt. Col. (Ret.)

John MacNamara, July 24, 2000. The

Mogadishu airfield was both the Rangers’

home base and the location of Gen.

Garrison’s operations center from which the

Ranger raid was being directed. Given the

SOC forces’ strong interest in preserving

secrecy, Marsh’s prior arrangements to use

the MASF as a casualty collection point, the

presence of Air Force medical personnel and

JSOC medics at the airport, and the proximity of the MASF to the scene of the attempted

seizure, the decision to use it as a kind of battalion aid station was a foregone conclusion.

73. Tel. interview, Marsh, June 28, 2000.

Lt. Rast had finished her voluntary tour of

duty before the Ranger’s attempt to seize

Aidid. However, Marsh praised her enthusiastically for her understanding and willingness to fulfil his requirements solely on the

basis of informal discussions. He credited her

efforts as major contributions to the effectiveness of the medical treatment his troops

received and offered highly laudatory comments that stressed how easy it was to work

with Rast. It seems reasonable to conjecture

that perhaps the major reason for this was

rooted in the generally less formal approaches their respective organizations, SOC and

the ANG, shared to the military context within which they performed their missions. 

74. Tel. interview, Lt. Col. Susan

Konczal, MSC, USAFR, June 1, 2000.

Konczal reports that Col. Volpe described the

use to which the MASF might be put but she

left discussion of the medical support that

might be required from the MASF staff and

other AF medical personnel at the airport to

direct conversations between them and the

426

Notes
Ranger task force surgeon, Maj. Marsh.

75. Tel. interview, Konczal, June 1, 2000.

Given the obviously high degree of secrecy

surrounding the SOTF mission and presence,

Konczal chose not to seek permission or

advice from her normal chain of command

prior to the operation. This was confirmed in

separate interviews by the OIC of the AE cell

in the TACC, Col. Wright, and Konczal’s

immediate superior, the director of AE forces

at Cairo West, Lt. Col. Hadbavny. Tel. interviews with Col. (Ret.) Sarah Wright, NC,

USAF, and Lt. Col. Eileen Hadbavny, NC,

USAFR, June 7, 2000 and July 11, 2000,

respectively. According to one of Gen.

Roadman’s medical planners, however, the

AMC SG staff realized how few medical

resources were available in Mogadishu and

had thought such a requirement might arise.

Lt. Col. (Ret.) Philip Mahlum, MSC, USAF,

May 30, 2000.

76. This propinquity in an otherwise highly austere and dangerous environment helped

generate unusually strong bonds among the

Americans at the air base particularly

between some of the female Air Force medical personnel and the troopers, many of

whom on both sides were quite young. This

made the later trauma of having to help deal

with the ‘troopers’ severe wounds and, in

some cases, deaths, quite severe, although

there is no evidence that their medical performance was affected adversely. In fact, the testimony of people such as Dr. Marsh indicates

that all performed admirably. Tel. interviews,

Col. Sylvia Nye, NC, ANG, June 26, 2000;

Sgt. Nicole Fagula, ANG, July 9, 2000. Wise

interview, July 9, 2000.

77. MacNamara indicates that it was difficult to get equipment sent from stocks at

Cairo West to increase the actual treatment

capability of the MASF because, by doctrine,

the MASF was only a holding facility for

patients scheduled for aeromedical evacuation. Most equipment and medicine that he

and the MASF staff obtained was cadged or

borrowed from the 46th CASH and the U.S.

Navy. Interview, Lt. Col. John MacNamara,

MC, USAF, July 19, 2000. 

78. Atto was seized on Sept. 21, during a

raid launched by JSOTF Commander, Gen.

Garrison, as a response to a mortar attack on

the JSOTF area at the airfield the night before

during which twelve mortars exploded on the

airfield. Warner–Levin Memo, Subj: Review

of the Circumstances Surrounding the

Ranger Raid, Sept. 29. 1995, 37–38, 47.

Capt. (Ret.) William F. Sims, USAF, Somalia

diary (San Antonio: Burke Publishing

Company, 1999), 71. Sims was chief of the

USAF command post at the Mogadishu airport from September 3 until December 2,

1993. Written in a highly informal style,

Sims’ privately printed diary contains his

observations on events and people that he

recorded with few exceptions each day of his

lengthy assignment. Ltr, Col. (Ret.) Carroll

Bloomquist, MSC, USAF, to the author, July

23, 2000. 

79. Tel. interview, Maj. (Ret.) Rob Marsh,

USA, June 28, 2000.

80. Ibid. According to a medical technician who had served in the MASF prior to Lt.

Rast’s arrival, the previous MASF OIC, Capt.

Duiker had anticipated the use of the MASF

for casualty care and conducted some exercises. Fagula interview, July 9, 2000. Capt.

Konczal indicates that she does not recall Dr.

Volpe discussing aeromedical evacuation

with her as part of his request to use the

MASF as a CCP. However, she automatically assumed that it logically followed and was

confident that her credibility with Col.

Wright in the TACC was such that the necessary aircraft for AE would be available. Ltr,

Konczal to the author, June 21, 2000.

81. For simplicity in the rest of this narrative, the term “Rangers” when used alone

will denote all elements of the SOTF in

Mogadishu, which included the Delta Force,

as well as the Army Rangers.

82. Tel. interview, Col. Robert Ditch,

MSC, USAF, June 12, 2000. At the time of

this writing, Ditch was the deputy comman427

Notes
der of the 363 Expeditionary Medical Group

stationed in Saudi Arabia. Volpe did not similarly take the 46th CASH commander, Dr.

Bruce Bailey, into his confidence, perhaps

because Bailey considered the secrecy the

SOC surgeons sought to impose on their

activities wildly excessive (“strange stuff”) in

the circumstances existing in Mogadishu. In

a recent interview, he reported that he was

awakened around two ‘one morning to find a

helicopter idling on his hospital medevac pad

with people still inside. Upon inquiring, he

was told that the helicopter contained a SOC

trooper suspected of having appendicitis and

a Ranger physician who was conducting the

medical evaluation inside the helicopter

because the Rangers wanted to preserve the

trooper’s anonymity. Tel. interview, Dr.

Bailey, June 27, 2000.

83. Ibid. Col. Hadbavny noted in her

report that, contrary to doctrine, the MASF

had also functioned as a primary care facility

and at times a staging area for mortuary services. After-action report, p. 12. The location

of the MASF on the airfield together with the

medical skills available in the Air Force AE

contingent made it the focal point for emergency care because transportation to the

Army Combat Support Hospital at the

embassy site required a helicopter after the

atmosphere turned hostile to the UN in early

June, and there was no other medical facility

on the airport. At least one highly experienced former AMC medical planner with

responsibility for AE in the command

applauded Maj. Konczal’s decision in a letter

to the author. Ltr, Col. (Ret.) Carroll

Bloomquist, MSC, USAF, to the author, July

23, 2000. Research reveals no post-facto criticism of Major Konczal’s decision nor

adverse effect on her subsequent career.

Medical planners at AMC were aware that

the MASF had already been used as an emergency aid station.

84. Tel. interview, Konczal, June 1, 2000.

Interviews, Lt. Col. (Ret.) Eileen Hadbavny,

June 29, 2000, Lt. Col. John MacNamara,

July 19, 2000. Both Hadbavny and

MacNamara have provided the author with

pictures of the ceremony held in the MASF

tent. Sims, Somalia diary, p. 186. The last

Rangers left Mogadishu on Oct. 27.

85. Sims prints lengthy edited excerpts

from the personal written accounts of two

Rangers, PFCs David Floyd and Brian

Heard, who were pinned down in Mogadishu

until rescued near dawn on Oct. 4 and transported to the stadium used by the Pakistanis

as a base. Somalia diary, pp. 114–24.

86. Tel. interview, Lt. Col. John

MacNamara, June 14, 2000. Marsh interview, June 28, 2000. According to Dr.

MacNamara, the two SOTF medical personnel had other responsibilities to their unit that

caused them to leave and return periodically.

Tel. interview, MacNamara, July 13, 2000.

Interview, July 19, 2000. MacNamara

worked continuously from the arrival of the

first casualties until the flow essentially

stopped just before midnight until early the

next morning. MacNamara’s recollections

are confirmed by the Asst. OIC of the MASF,

Maj. Susan Martello, NC, ANG. Tel. interview, Martello, July 19, 2000. As noted earlier, the immediacy of the experience with the

seriously wounded Rangers was difficult for

some of the less-experienced Air Force personnel. Tel. interviews, Staff Sgt. Nicole

Fagula, ANG, July 9, 2000; Lt. Col. Susan

Konczal, June 1, 2000. Ltr, Col. (Ret.)

Carroll Bloomquist, MSC, USAF, July 23,

2000.

87. Bowden, p. 228. The AELT chief,

Susan Konczal, commented in a recent interview appropos Bowden’s book that while his

account of most events seems correct from

her observations, “he got the medical parts all

wrong.” Konczal tel. interview, May 18,

2000. In a subsequent Ltr, she affirmed her

earlier view that Bowden’s account may be

considered “authoritative from an operational

perspective but not from a medical perspective.” Ltr to the author, June 21, 2000. All Air

Force participants in the events of Oct. 3–4

428

Notes
contacted by the author, challenge Bowden’s

account of the medical support provided the

SOC casualties. In a recent interview, the

46th CASH Commander indicated that he

thought the measures that the SOC surgeons

used to preserve the anonymity of the

Rangers were faintly ridiculous. Bailey tel.

interview, June 27, 2000. Appropos this

extreme concern with security, the anesthesiologist at the 46th CASH remarked in another recent interview that when the first SOC

casualties arrived at the CASH, the initial

attitude of two SOC surgeons present was to

tell the CASH physicians they must leave the

operating room while the SOC physicians

handled their casualties. In fact, this procedure had been followed previously when single Rangers had needed emergency treatment, but it was quickly abandoned on Oct.

3rd since it was manifestly impractical in the

circumstances prevailing especially as more

casualties began to arrive. Two SOC physicians were billeted with their medical counterparts assigned to the CASH but said nothing about the nature of the SOC forces’ mission other than to urge the CASH physicians

to establish an alert status during off-duty

hours. Tel. interview, Col. Denver Perkins,

MC, USA, June 26, 2000. Col Perkins is now

the Chief of Anesthesiology at the Walter

Reed Army Hospital.

88. Tel. interview, Martello, June 8, 2000;

tel. interview, Konczal, June 1, 2000.

Hadbavny after-action report, p. 19. Tel.

interview, Konczal, July 11, 2000. Konczal

observed and participated in the casualty

reception and treatment on the airport and in

the MASF/CCP.

89. Tel. interview, Lt. Col. Konczal, June

13, 2000. Tel. interview, Moshman, July 8,

2000. Tel. interview, Wise, July 9, 2000. Tel.

interview, Martello, June 8, 2000; tel. interview, Konczal, June 1, 2000. Hadbavny afteraction report, p. 19. Tel. interview, Konczal,

July 11, 2000. These validation visits to the

CASH were routine prior to the regular

Monday AE missions. As in Desert

Shield/Desert Storm, an immediate concern

of the 46th CASH commander was the need

to clear patients from his hospital as quickly

as possible to make way for the casualties of

combat on October 3–4 who would also need

to be aeromedically evacuated as quickly as

possible because the bed capacity was relatively small and further attacks were expected. Patients in the hospital when news of the

casualties first arrived were distributed to

some of the U.S. medical organizations

attached to the U.S. Army combat units that

composed the quick-reaction force. Tel. interview, Dr. Bruce Bailey, June 27, 2000.

90. In a recent interview, Col. Ditch indicated that he was aware that, in addition to

the C–141 at Cairo West scheduled to fly the

normal Monday AE mission to Mogadishu

the next day, another C–141 was on the

ground at Cairo West. Concerned that the

46th CASH had only a few empty beds by

late Sunday evening and unsure what new

casualties the next day might bring, he had

asked Captain Konczal to request that the

first evacuation aircraft arrive before dawn

around four in the morning to clear the

CASH of patients and have the second arrive

at the normal arrival time around seven that

morning to be in place to take any new casualties that the Rangers might suffer. Konczal

confirmed Ditch’s account in a recent interview; however, she said that she did not

request such an evacuation sequence because

she did not believe the patients could be readied for aeromedical evacuation to meet a

predawn departure. Events validated her

judgment. Tel. interview, Ditch, June 12,

2000. Tel. interview, Konczal, June 13, 2000.

It should also be noted that the policy was not

to conduct flight operations at night because

they drew ground fire.

91. Tel. interview, Lt. Col. Lewis Bartles,

July 12, 2000. Dr. Bartles, a flight surgeon

from the 31st AES (Associate Reserve),

Charleston AFB, was enroute to Mogadishu

for a thirty-day volunteer tour to relieve Dr.

MacNamara, the MASF flight surgeon.

429

Notes
Bartles had been scheduled to fly to

Mogadishu from Cairo West on the regular

Monday AE mission, but helped mobilize the

medical personnel and equipment drawn

from the ATH that went aboard the C–5.

Originally, the ATH personnel had been

scheduled to fly with Dr. Bartles on the

C–141 but were not ready to go when it

departed, so they were placed aboard the

C–5. Interview, Lt. Col. Eileen Hadbavny,

NC, USAFR, July 14, 2000. Bartles noted in

the interview that several of the CASH personnel were critical of the lack of Air Force

support. Ground fire directed at the airport

during daylight hours was an unusual occurrence that forced the C–5 to not land. Tel.

interview, Capt. (Ret.) William F. Sims,

USAF, July 23, 2000. Sims, chief of the airport command post, reports that the C–5 was

directed to orbit at altitude for some time

before being directed to return to Cairo in

view of the continuing ground fire.

92. Dr. Bartles reports that the medical

capabilities of the Cairo ATH had been progressively reduced. Upon arrival at

Ramstein, the patients were removed from

the C–141 by personnel from Brannon’s 86th

AES and transported to the Landstuhl Army

Medical Center. Two were on ventilators, one

with a double pneumothorax. The other had a

head wound and could not be treated adequately at Landstuhl because no neurosurgeon was present, and he was flown by C–9

to Hamburg for civilian hospitalization. Tel.

interview, Bartles, July 12, 2000. 

93. Hadbavny after-action report, pp. 16,

19–20. Tel. interviews, Konczal, June 1 and

June 6, 2000. Tel. interview, Martello, June 8,

2000. Tel. interview, Nye, June 26, 2000.

Many of the evacuees were fresh postsurgical

patients who were stabilized sufficiently to

the satisfaction of the physicians at the hospital to survive the flight to Ramstein.

However, because of their condition, an

attendant to supplement the normal medical

flight crew was required, and, rather than

require the CASH to provide one from

among the limited number of physicians

assigned as would have normally been done,

Col. Bartles, the flight surgeon who had

arrived to replace Lt. Col. John MacNamara,

accompanied this first load of evacuees. Lt.

Col. MacNamara voluntarily remained in

Mogadishu rather than leave the Air Force

personnel short of a physician’s skills during

Bartles’s absence. Bartles had been sent to fill

a “gap” until 9th Air Force could provide

another active duty flight surgeon and allow

MacNamara to take his board examinations

in aerospace medicine. He left only in midOctober. Hadbavny after-action report, p. 20.

Tel. interview, Bartles, July 17, 2000. The

second C–141 AE mission was accompanied

by a U.S. Navy flight surgeon, Dr. Gordon

Moshman. Tel. interview, Col. MacNamara,

June 13, 2000. Col. MacNamara was

assigned to Pope AFB at the time of this

interview. Tel. interview, Dr. Gordon

Moshman, July 8, 2000.

94. Bowden, Black Hawk Down, and

Kent DeLong and Stephen Tuckey,

Mogadishu! Heroism and Tragedy (Wes -

tport, Conn.: Praeger, 1994). Bowden discusses medical care for the wounded (pp.

227–79, 265–66, and 292–99) but never

mentions anything about the work of the

flight nurses’ nor other Air Force medical

contributions. In his discussion of the medical support the Ranger casualties received,

Bowden focuses his account around the person of Maj. Rob Marsh, the Delta Force surgeon, the son of the Secretary of the Army,

who was later wounded seriously in the

stomach by a mortar round during Aidid’s

retaliatory attack on U.S. forces at the

Mogadishu airport the following Thursday.

Marsh was well liked by the Air Force personnel and is reported to have said that the

nurses who attended to him immediately

after he had been hit had saved his life. By

several accounts, the Rangers and the flight

nurses had “bonded,” the former coming to

regard the latter as their protectors, which

made their work in the MASF assisting with

430

Notes
the Ranger casualties doubly traumatic. One

of the Ranger officers later married an ANG

flight nurse from the Air Force contingent at

the Mogadishu airport. Tel. interview,

Martello, June 8, 2000. Tel. interview, Grae

Brown, June 4, 2000. Tel. interview, 1/Lt Wes

Hamilton, MSC, ANG, June 7, 2000. 

95. The quotation is from Mogadishu!

Heroism and Tragedy, p. 85. Although the

presence of flight nurses undoubtedly provided a small measure of comfort to those of the

casualties whose wounds were not so severe

that they could not appreciate it, as noted in

the text, the flight medical personnel who

were present at the Mogadishu airport tell a

different story. One very brief description of

events at the MASF is TSgt. Timothy P.

Barela, “Bloody Sunday,” Airman (Feb.

1994). Nurses and medical technicians are

quoted in the article about conducting triage

on all the wounded soldiers on litters who

began to pour through the airport gate, and

according to ‘the memory of one, “kept coming and coming.” The author of Black Hawk

Down does characterize the Delong and

Tuckey book as a “hasty, sincere effort,” that

is, however, “full of mistakes.” However, the

exclusion of the nurses’s efforts shows an

ignorance of events that is more profound. A

module in the Special Operations Medic

Course, “Mogadishu Raid Exercise,” refers

to the CCP at the airport several times, only

once referring to as the “CCP/MASF.” In all

fairness, the focus of this exercise is on what

SF medics can learn about how to conduct

themselves in critical situations like

Mogadishu and clearly is not meant to slight

the Air Force role. I am indebted to Col. Cliff

Cloonan, MC, USAF, Dean of the Special

Operations Medical Training Center at Fort

Bragg, for a copy of this exercise.

96. Gen. Fogleman, then CINCTRANS/

Commander AMC, recalled seven years after

the event that the only mention of the use of

the MASF as an emergency medical facility

was made at one of the standard morning

briefings and presented as the Air Force “was

able to help,” with no further elaboration. Tel.

interview, Gen. Ronald R. Fogleman, USAF,

June 28, 2000.

97. Handwritten draft of a letter from Col.

Bartles, and Lt. Col. MacNamara with Lt.

Col. Volpe’s handwritten concurrence, to

“AMC Medical Command” [sic], Oct. 8,

1993; whether a final draft was prepared and

sent is not known. However, Col. Hadbavny

sent a letter to AMC incorporating the details

of a briefing and recommendations she had

received at Cairo West from Col. Bartles

immediately prior to his return to Mogadishu.

In a letter dated Oct. 7. and based on a handwritten draft left her by Bartles, Col.

Hadbavny reported that the limited number

of beds at the 46th CASH meant that the

MASF would again become a CCP in future

mass casualty (MASCAL) situations and recommended that two to three “acute care doctors,” one of them being available to augment

the standard medical flight crew for urgent

missions, be deployed to augment the MASF

staff. Bartles also recommended that consideration be given to upgrading the MASF to a

second-echelon MTF. Ltr, from Director, AE

Forces [Hadbavny], to AMC/SGPC, subj:

Direct Field Assignment of 4 Oct 93 Casualty

Evacuation from Mogadishu, Somalia, with

Recommendations, Oct. 7, 1993. Hadbavny

papers. Although, as of July 1993, the

C–130s and the tactical AE mission had been

reassigned to the Air Combat Command,

AMC kept responsibility for the Somalia

operation for purposes of continuity.

Reportedly, when the request for additional

physicians was referred to the ARC, the

responsible officer said, “Doesn’t she know

that we’re drawing down?” Tel. interview,

Hadbavny, June 11, 2000. However, two

additional flight surgeons were, in fact, dispatched to Mogadishu in mid-October 1993.

Hadbavny after-action report, p. 3.

98. Tel. interview, Brig. Gen. Jerome

Foust, MSC, USA, Mar. 3, 1999. See

Chapter 8.

99. Tel. interview, Wright, June 7, 2000.

431

Notes
Col. Wright reported that special forces’ representatives sat in the TACC several times

during her tenure in the TACC (from June

1992 to November 1995) to help coordinate

required airlift for some highly classified

missions. The after-action report on the AE

system established for the Haiti operation

was much more “joint” in concept and,

among other things, included deployment of

the medical regulating elements prescribed

doctrinally by Joint Pub 4.02.02, which was

not to be promulgated formally until two

years later. The AE system deployed for the

Haiti operations is described in the afteraction report conveyed by Memo for HQ

AMC (TPMRC Augmentees), USTRANS -

COM (GPMRC), Wilford Hall Med Ctr

(CCAT Personnel), et al., from Col. Thomas

M. Chester, MSC. USAF, subj: Aeromedical

Evacuation After Action Report – Operation

Uphold/Maintain Democracy, n.d. [routing

slip stamp dated Jan 11, 1995]. I am indebted

to Lt. Col. Susan Konczal, MSC, USAF, for

a copy of this report.

100. There is a useful chronology in

Margaret Daly Hayes and Gary F. Wheatley,

Interagency and Political-Military Dimen -

sions of Peace Operations: Haiti – A Case

Study (Washington, DC: National Defense

University [NDU], Feb. 1996. This publication reports on one of a series of workshops

conducted by NDU’s Institute for National

Strategic Studies. It focuses on process primarily and does not treat medical support of

the Haiti operation. Interestingly, two items

from its list of “What Went Right” in Haiti:

viz., “adequate resources for the job” and

“commanders had the latitude to do the job,”

could be taken as negative commentaries on

the U.S. role in Somalia, not just on the

restrictions placed on the U.S.-manned Quick

Reaction Force but also on the AE system

which supported Operation Continue Hope.

At least with regard to performing their medical support mission, the initiative and

aggressiveness of the AE personnel at

Mogadishu transcended some of the obstacles that policy inadvertently placed in their

way.

101. Tel. interview, Hartley, Aug. 21,

2000. Bob Shacochis describes the activities

of various Special Operations’ detachments

that he observed while in Haiti for several

weeks after the unopposed arrival of CJTF

190 at Port-au-Prince. Bob Shacochis, The

Immaculate Invasion (New York: Viking,

1999).

102. Ibid., pp. 16–17. Chester, Uphold

Democracy after-action report, p. 1.

103. On July 1, 1994, the 1st AES was

deactivated and the 23rd AES activated, with

no change in mission, location, or personnel.

104. For example, the Knightly Rogue

after-action report noted that the “user” wanted to utilize the 1st AES “in a diversion from

standard TAES mission,’” and that the “standard MASF package is inefficient for this

type operation,” whose new operational

requirements were for “more trauma/emergency nursing care skills.” SOC medical personnel provided the Air Force participants

with a lengthy list of lectures that clearly

related to emergency medicine and the evacuation of “stabilized” patients rather than the

MASF’ doctrinal role of patient holding and

stable patient evacuation. The subjects of

these lectures included abdominal trauma,

thoracic/chest injuries, burn assessment and

emergency care, vascular injuries, trauma

patient care and shock, battlefield anesthesia,

and wound ballistics. Quotes are extracted

from Knightly Rogue after-action report,

paras: 13.1.2-3, 13.7.1, and 13.18.4. The

“user” also requested that the first AE mission be planned for patients supported by six

ventilators, which, by AMC regulation,

would have required attendants that the

“user” was not necessarily ready to provide.

In a recent conversation with one of the 1st

AES planners who developed the CONOPS

for the Haiti operation, Dr. Volpe cited the

Panama medical support and evacuation system at Howard as the model he had wanted

for the AE system supporting the SOCOM

432

Notes
force deploying to Haiti. Tel. interview, Maj.

James Lorraine, NC, USAF, July 17, 2000.

At the time of this interview, Maj. Lorraine

was assigned to the Joint Staff J4, Medical

Readiness Division. Lorraine wrote the

CONOPS for both Knightly Rogue and

Restore Democracy. The nature of Exercise

Knightly Rogue and its relationship to the

CONOPS for the Haiti operation was also

confirmed in separate tel. interviews by the

former director of operations for the 1st AES,

Lt. Col. Kernist T. Stovall, MSC, USAF, July

23, 2000, and the drafter of the after-action

report, Lt. Col. Susan Konczal, July 17, 2000.

As Dr. MacNamara observed in a recent

interview, “Dr. Volpe and the medical elements of the SOC got exactly what they

wanted for medical support in Mogadishu.”

Tel. interview, July 24, 2000. Clearly, the

Somalia experience was a stimulus to the

SOCOM institutional memory of the concept

of integrating JSOTF medical personnel and

Air Force AE elements that had proved so

successful at Howard AFB during the

Panama operation five years before.

105. Tel. interviews, Maj. James

Lorraine, July 17 and 25, 2000; Tel. interview, Stovall, July 23 2000. Tel. interview,

Konczal, July 17, 2000. Theater command

was exercised by the Atlantic Command

(USACOM), and its component, Air Combat

Command, tasked the 23rd AES to do the

planning for the needed TAES. The Deputy

USACOM surgeon, Col. Felix Meyer, was a

former commander of the 1st AES during the

Grenada operation and one of the key planners of the medical support and the AE system that supported Operation Just Cause in

Panama. He noted in an interview with the

author that the latter was the original “template” for the Haiti planning. Tel. interview,

Col. (Ret.) Felix Meyer, MSC, USAF, Aug.

18, 2000.

106. There is a consensus among the

group that actually did the planning that

Reay, an MSC officer with a very considerable experience in AE planning and operations, was the driving force in the planning

process. Tel. interview, Hartley, Aug 21,

2000; tel. interview, Riley, Aug. 18, 2000; tel.

interview, Bouchard, Aug. 21, 2000. Reay

had been alerted to the interest of the special

operations community in Gen. Carleton’s

CCATT proposals (discussed later), and

Reay was later instrumental in developing

the participation of ACC active duty and

ARC AE units in the Joint Readiness

Training Center on the basis of discussions

with the 18th Airborne Corps Command

Surgeon, Brig. Gen. James Peake. The planning group conducted their sessions in secure

facilities at various locations including Fort

Bragg, MacDill AFB, and Hurlburt AFB, and

those planners who were focused on AE support of the conventional forces were not privy

to the details of that being developed for the

JSOTF. 

107. Chester, Uphold Democracy afteraction report, p. 9. Tel. interviews, Col.

Randy Hartley, MSC, USAF, Aug. 21, 2000;

Col. (Ret.) James D. Reay, MSC, USAF,

Aug. 18, 2000; Col. (Ret.) Felix Meyer,

MSC, USAF, Aug. 18, 2000. Col. Hartley

used the term “post-anesthesia recovery unit”

in referring to the MASF. Col. Meyer cited

Col. Volpe’s specific reference to the medical

and AE support at Howard AFB during Just

Cause as the “template.”

108. According to senior Air Force MSC

officers who were present, the then Brig.

Gen. P. K. Carleton from the Air Education

and Training Command (AETC) briefed the

Air Force Special Operations Command

(AFSOC) staff in early 1994 about Air Force

“mini-surgical teams” and CCATTs that

could augment standard Air Force medical

flight crews for the evacuation of patients

who were not clinically stable. However,

Carleton indicated that the teams regularly

used specially designed equipment that was

intended to deploy with the teams. However,

the equipment had been funded for use in the

AETC MTFs with AETC funds, which

Carleton believed should be repaid to free it

433

Notes
for “on call” use. AFSOC had both funds

available and an interest in the capability

CCATTS represented to provide care in the

air, something that JSOC surgeons, particularly Col. Volpe, had been pressing AFSOC

to develop. The upshot was that AFSOC

transferred funds ($180,000) to AETC, and

the surgical teams and CCATTs were placed

in a 24-hour response position and later

included in the planning for the Haiti operations. Tel. interviews, Col. Randy Hartley,

MSC, USAF, Dep. Command Surgeon,

CENTCOM, Aug. 21, 2000; and Col. David

Hammer, MC, USAF, Director, AF Medical

Operations Agency (AFMOA), Aug. 31,

2000. At the time of the Carleton briefing,

Hartley was the deputy command surgeon of

AFSOC and its chief administrative officer;

Hammer was the command surgeon and

Hartley’s boss. The chief medical planner of

the 23d AES who subsequently was one of

the planning group that developed the AE

CONOPS for Operation Uphold Democracy

also heard a similar briefing given by Gen.

Carleton’s staff as did Col. Sheila Millette

who was serving as the chief nurse for ACC

at the time. Tel. interview, Capt. James

Lorraine, NC, USAF, July 17, 2000; tel.

interview, Col. Sheila Millette, NC, USAF,

Aug. 25, 2000. Col. Millette had previously

served in the 1st AES and deployed with Col.

Brannon to establish the MASF/JCCP at

Howard AFB for Operation Just Cause. 

109. Col. Thomas M. Chester,

Aeromedical Evacuation After Action Report

–Operation Uphold/Maintain Democracy,

n.d. [routing stamp marked with date of Jan.

11, 1995], pp. 1–5.

110. One manifestation was a delay in the

planned relocation of the MASF from

Guantanamo Bay to Port-au-Prince, which

had to be delayed because of ongoing operations by the JSOTF. The result was an

unplanned reconstitution of an AEOT at

MacDill AFB into a MASF and its deployment to the Haitian capital. Chester, Uphold

Democracy after-action report, pp. 7–8.

111. Tel. interviews, Maj. James Lorraine,

NC, USAF, July 23 and 25. Ltr to the author,

Aug. 8, 2000. Lorraine notes that, as director

of the AECC at Pope, he had to request aircraft for the evacuation of “urgent”

patients–that is, those requiring aeromedical

evacuation as soon as possible–on three successive days. On the first occasion he directed that the AELT deployed on USS Comfort

have the approximately thirty patients aboard

medevaced to shore to take advantage of the

unscheduled aeromedical evacuation aircraft.

However, he had to make requests for aircraft

to carry out the aeromedical evacuation of the

later “urgents” because his inquiries why the

patients could not find the definitive treatment they required on the Comfort elicited

the information that the humanitarian mission of the hospital ship had taken priority.

Chester, Uphold Democracy after-action

report, p.4.

112. The CONOPS for a forced entry

called for the AELT deploying to Port-auPrince to parachute in. Tel. interview, Stovall,

Aug. 2, 2000; tel. interview, Lt. Col. Konczal,

MSC, USAFR. Konczal was OIC of the

AELT at Jacksonville Naval Air Station.

Chester, Uphold Democracy after-action

report, pp. 12–13.

113. Chester, Uphold Democracy afteraction report, pp. 7. The 28th CASH assumed

all medical regulating and treatment capabilities for the AOR on October 2. Chester’s

after-action report states that it had been

planned that the MASF/JCCP supporting the

JSOTF at Guantanamo would be moved to

Port-au-Prince (PAP) some forty-eight hours

after the deployment of U.S. forces began

when the JSOTF operations were supposed

to be over. However, the AE personnel were

not “chopped” back to the director of AE

forces until several days later, and a MASF

for PAP was constituted using personnel

from the AELT at MacDill augmented by

others from the AFRES 610 AES. This detail

is worth noting because the retention of the

MASF at Guantanamo seems to have been a

434

Notes
direct result of caution growing out of events

in Mogadishu. There, the early withdrawal of

a significant part of the U.S. combat capability that had initially overawed the Somali

warlords had been followed by the hostile

resurgence of the warlords, culminating in

the disaster growing out of the Rangers’

attempt to seize Mohammed Aidid. See the

Warner–Levin Memo, “Review of the

Circumstances Surrounding the Rander Raid

on October 3–4, 1993, pp. 4–5. This explanation for the MASF/JCCP’ retention was

offered by a former ACC medical planner

who had just been reassigned to AMC at the

time of Uphold Democracy. Tel. interview,

Lt. Col. (Ret.) Mark Hamilton, MSC. USAF,

Aug. 2000.

114. Chester, Uphold Democracy afteraction report, p. 7. Tel. interview, Lorraine,

July 25, 2000.

115. Tel. interview, Lt. Col. (Ret.) Philip

Mahlum, MSC, USAF, Aug.23, 2000.

Mahlum had moved from the AMC

Command Surgeon’ planning staff to the

newly established GPMRC. The deployed

DMRTs were from his new office. Chester,

Uphold Democracy after-action report, pp.

10–11. 

116. Tel. interview, Lorraine, July 25,

2000. Tel. interview, Mahlum, Aug. 23, 2000.

117. Tel. interview, Mahlum, Aug. 23

2000. Based on the demonstrated utility of

this equipment, AMC subsequently procured

six INMARSAT terminals. Chester, Uphold

Democracy after-action report, p. 10.

According to Maj. Lorraine, the crews were

also provided with pictures of the OICs of the

several deployed AELTs that would have

directive authority over issues related to

patient evacuation. Tel. interview, Lorraine,

July 25, 2000.

118. Quoted in the after-action briefing on

the TAES by the then Capt. Lorraine at Pope

AFB, n.d. I am indebted to Lt. Col. Konczal

for a copy of the briefing slides. Maj.

Lorraine verified the quotation in a recent letter to the author.

119. Some JULLS entries were quite

basic. JULLS 11.15 observed in a discussion

of how mixed active duty and ANG AE

crews performed that several ANG AE

crewmembers were not physically able to lift

patient litters into the fourth and fifth litter

tiers and noted that “physical fitness is a must

to accomplish the mission and stay healthy.”

A number of other JULLS entries were not

criticisms but descriptions of procedures and

adaptations to changing circumstances that

the particular entry recommended be continued or included in doctrine and policy. The

relevant JULLS entries are attached to

Chester’s Uphold Democracy after-action

report. Lorraine in the after-action briefing

cited in a previous footnote listed six items

under the heading “What we can do better”:

improve AECM preparation, develop

employment concept for DMRT, exercise

and equip AE crew augmentee concept,

improve AE equipment readiness/availability, formalize doctrine to meet customer

requirements, and acquisition of joint medical communications.

120. Tel. interview, Col. (Ret.) Daniel

Reay, MSC, USAF, Aug. 18, 2000. Col. Reay

served as the Surgeon of the Air Force

Component (AFFOR) of the Joint Task

Force.

121. I am indebted to Lt. Col. Mahlum for

this insight.

122. ACC Surgeon’s Office, “ACC

Surgeon’s Program to Improve Casualty

Care,” n.d. [ca. Jan. 1995]. I am indebted to

Lt. Col. John Felins, MSC, USAF, for a copy

of this program description. Tel. interview,

Lt. Col. Felins, Aug. 17, 2000. Tel. interview,

Lt. Col. (Ret.) Mark Hamilton, MSC, USAF,

Aug. 20,2000. Tel. interview, Col. (Ret.)

James D. Reay, MSC, USAF, Aug. 18, 2000. 

123. Reay believed that AMC headquarters did not have a strong interest in tactical

AE, which the AMC leadership tended to

consider, like the C–130s, part of “Little

MAC,” that is, the nonstrategic airlift units

that were the most important instruments for

435

Notes
conducting the TRANSCOM/AMC’ principal wartime mission of deploying U.S. personnel and equipment to support U.S. theater

commanders. When queried by the author

what ‘the reaction of AMC was to the policies embodied in the CONOPS for Operation

Uphold Democracy, which varied so sharply

from those AMC policies governing intertheater patient movement, Reay indicated he

was indifferent to the reaction of AMC

because he viewed AMC as an obstacle to

progress because of its focus on strategic AE.

Tel. interview, Reay, Aug 19, 2000. 

124. The quotation is from the ACC

CONOPS for Theater Aeromedical

Evacuation System Assets, Feb. 15, 1995,

signed by the ACC Surgeon, Brig. Gen.

Thomas D. Gensler, MC, USAF. Formally

promulgated after Operation Uphold

Democracy had been planned, this approach

obviously permeated the CONOPS for the

Haiti operations, but its deliberate use as a

guide is confirmed by one of the ACC planners involved. Tel. interview, Lt. Col. John

Felins, MSC, USAF, Aug. 17, 2000. Felins is

generally credited with being the author of

the CONOPS and also shared Reay’s opinion

of AMC’s lack of understanding and responsiveness toward the tactical AE mission. ‘Tel.

interview, Felins, Mar. 22, 2000.

125. Tel. interview, Hartley, Aug.21,

2000. Hadbavny after-action report, p. 19.

126. Tel. interview, Lorraine, July 17 and

25, 2000. Major Lorraine’s account of the

meeting has been supported by Col.

Bloomquist, although he remembers the

audience as being agitated at times but perhaps somewhat less vociferous than Maj.

Lorraine recalls. Ltr, Col. (Ret.) Carroll

Bloomquist, MSC, USAF, to the author, July

23, 2000. Lorraine briefed his squadron commander and operations officer about this

meeting after his return, and the latter confirmed recently that Lorraine’s account of

this meeting to the author is the same as he

heard in late April 1994. Tel. interview, Lt.

Col. (Ret.) Kernist Stovall, MSC, USAF,

Aug. 2, 2000. The subjective element in perceptions presumably is at work here. Maj.

Lorraine, was, of course, stationed for some

eight months in Mogadishu during Restore

Hope and Continue Hope. Additionally,

because Lorraine was an Air Force nurse, a

medical professional, he would undoubtedly

have acutely felt accusations reflecting on the

quality of medical care. I am indebted for this

insight to Col. Stovall. The key issue, in any

event, is how Lorraine perceived the Army

criticisms because these affected his

approach to the CONOPS he would be

tasked to write a few short months later.

127. Both casualty care air transport

teams (CCATTs), flight surgeons, multiple

AELTS and MASFs (beefed up to serve as

CCPs as needed), an AECC, and significant

numbers of AECMs “staged” to man AE

flights carrying U.S. casualties and other

patients were all part of the AE forces

deployed. In spite of the success of the program to track PMI, there were still difficulties

with Army medical logistics, which failed to

resupply the 28th CASH with litters, litter

straps, and blankets in the mistaken belief

that the Air Force was required to exchange

these items for those sent from the CASH

with patients who were aeromedically evacuated. The MASF at Port-au-Prince filled

these shortages for the CASH. JULLS entry

11.38. Chester, Uphold Democracy afteraction report. Tel. interview, Hammer, Aug.

31, 2000.

128. Tel. interview, Lorraine, July 25,

2000. This major change in doctrine was confirmed by the 23rd AES Operations Officer,

Col. Stovall, who was present at the Port-auPrince airport during the initial days of the

U.S. intervention at the specific request of the

commander of the 18th Airborne Corps’ 44th

Medical Brigade, Col. Peake. Peake, the

army’s fortieth surgeon general, interacted

frequently with the staff of the 23rd and

asked Stovall to deploy to Haiti to monitor

the aeromedical evacuation system as it went

into operation. Although on active duty and

436

Notes
well trained, OICs of AELTs were generally

company grade officers. Lorraine’s description of the restriction on MCD’s right to

refuse patients is confirmed by the other

planners including Col. Reay.

129. Ibid.

130. Quotation is from comments provided by Gen. Downing for the then Lt. Col.

Randy Hartley’s performance evaluation. I

am indebted to Col. Hartley for this information. Tel. interview, Aug. 21, 2000. In a separate interview, Hartley’s boss, Col. Hammer,

then the AFSOC surgeon, attributed the same

comment to Gen. Downing in exactly the

same words.

Chapter Twelve

1. Tel. interview, Lt. Col. (Ret.) Philip

Mahlum, MSC, USAF, Aug. 23, 2000.

2. It is not clear to what degree medical

support including AE requirements has been

factored into military planning overall. A

highly experienced former Army medical

corps physician who participated in a highlevel wargame at the Army War College

(AWC) in early 1999 reported that a number

of medical issues raised by the U.S. Army

medical department representatives were

termed “war stoppers” by the wargame director who said that these would need to be considered in future games. A recent “Army

Transformational Wargame” at the AWC

involving the Army chief of staff and a very

senior group of “players” from all services

reportedly was very concerned about better

defining the logistics requirements of the

Army “objective force,” which the wargame

was designed to evaluate. For a lengthy

report on the game, see Jason Sherman,

“Coming Attraction: At Play in the Fields of

the Future with the Army’s Objective Force,”

Armed Forces Journal International (July,

2000), pp.: 40–44. Whether medical requirements were part of the logistics discussions is

not mentioned in this brief article. However,

one retired general “”who participated noted

that the objective force requires new investments in ships and planes to carry it, an

observation that might have negative potential implications for any future reengineering

of the Air Force’ AE capabilities that require

any significant budgetary increases.

3. The Joint Chiefs of Staff published successive “Joint Vision” documents with

advancing dates that have been echoed by the

services and the AMC medical planners. 

4. By June 1994, the Air Force no longer

regarded the service life extension program

as a viable option. Air Mobility Command

History, 1 June 1992–31 Dec. 1995, Vol. I:

Narrative, (Scott AFB, Ill.: Office of History,

Air Mobility Command, July 1995), p. 374.

AMC/HO. 

5. Capt. Don Wasik, Point Paper, subj:

Stage III Noise Commpliance, Aug. 6, 1999.

AMC/HO.

6. Gen. Walter Kross, USAF, CINCTRANS/AMC commander, discussed with

some urgency the need for C–5 funding at an

“Air Mobility Symposium: 1947 to the

Twenty-First Century,” Sept. 19–20, 1997,

which the author attended. Gen. Kross also

discussed C–5 modernization in his oral history. Kross, An Oral History, pp. 50, 53. His

predecessor, General Robert Rutherford, also

expressed concern over the low C–5 reliability rate for both models of the C–5, which he

asserted ranged from 65 to 75 percent when

90 percent was necessary for AMC to meet

its mission. Gen. Robert L. Rutherford,

USAF, An Oral History (Scott AFB, Ill.:

TRANSCOM Research Center, October,

1996.), p. 31. Kross’s successor, Gen. Charles

T. Robertson, USAF, also identified C–17

acquisition and C–5 modernization as his two

top priorities for FY99 funding. “Air

Mobility Master Plan Update,” AMC

History, 1996–1998, p. 3. AMC/HO.

7. The then AMC surgeon, Brig. Gen.

John Jernigan, MD, USAF, had requested

that the Air Force Institute of Technology

(AFIT) conduct a study assessing replacements for the C–9s, and it was done as an

437

Notes
AFIT thesis by Maj. Scott A. Wilhelm,

USAF. “An Analytic Tool to Assess

Aeromedical Evacuation Systems for the

Department of Defense,” Mar. 1998.

AMC/HO. Procuring a possible replacement

for the C–9 may ultimately parallel the

course of the its own original procurement.

As a projected replacement for the C–131,

the propeller-driven first Air Force aircraft

dedicated to AE, the C–9 twice failed to

secure Air Force funding until President

Johnson’s visit to Vietnam early in the

Vietnam War when he spoke approvingly

about aeromedical evacuation after touring

an aircraft configured for AE. See Chapter 7.

8. Quote from Executive Summary,

Report of Audit, Review of the Aeromedical

Evacuation System, p. 1. Audit transmitted

by Memo for the Secretary of the Air Force

and Chief of Staff, USAF, from Jackie R.

Crawford, The Auditor General, July 5, 1995.

Air University Library, Maxwell AFB,

Alabama.

9. [Betty Kennedy], Issue Paper, “C–9A

Replacement Issues/ Strategy,” n.d. [ca. Apr.

1999]. AMC/HO.

10. Ibid.An earlier audit of the AE system

in 1977 had also recommended halving the

C–9A flying-hour program (for FY 1978 it

was programmed to be 25,806 hours) for

similar reasons of cost ineffectiveness.

However, the wartime mission for the

domestic C–9A fleet adopted in the mid1980s–that is, deployment to Europe to support movement of casualties from a

NATO–Warsaw Pact conflict to contingency

hospitals–provided a rationale for resisting

such a large cut. Draft Report on the Audit of

the Worldwide Aeromedical Evacuation

System, p. 8. Report transmitted by Memo

for ASD/HA and Asst. Secretary of the Air

Force from James H. Curry, Associate

Director, Systems and Logistics Audit, Nov.

6, 1978. AMC/HO.

11. Issue Paper, Draft Report of Audit.

Worldwide AE System, July 5, 1995, p. 20.

12. Ibid., pp. 21–22. Although he gave his

top priority for funding to C–17 acquisition

and C–5 modernization in that order, Gen.

Robertson listed “C–130X modernization” as

his third. Acquisition of C–130J models was

another key issue with which AMC had to

deal.

13. Interview, Lt. Col. Rita Kerrick. Col.

Kerrick was commander of the 459th AES,

AFRES, which was assigned to an AFRES

C–141 wing based at Andrews AFB, Md.

14. AMC History. AMC/HO. Tel. interview, Maj. Gen. P. K. Carleton, MC, USAF,

1998. Tel. interview, Lt. Gen. James

Roadman, MC, USAF.

15. Maj. Scott Wilhelm, Point Paper, subj:

C–9 Replacement, Jan. 19, 2000. AMC/HO.

Maj. Wilhelm conducted the C–9 study that

was delivered to Gen. Jernigan’s successor,

Maj. Gen. Randolph, CENTAF surgeon during Desert Shield/Desert Storm, and, subsequently, CENTCOM surgeon prior to his

assignment as the TRANSCOM/AMC surgeon. 

16. Tel. interviews, Col. (Ret.) Sarah

Wright, NC, USAF, Sept. 9, 2000; Lt. Col.

(Ret) Philip Mahlum, Aug. 8, 2000; Col.

Sheila Millette, NC, USAF, Aug. 25, 2000.

Col. Millette was codirector of the Tiger

Team.

17. Aeromedical Evacuation Tiger Team

Final Report, June 19, 2000. AMC/HO. Tel.

interview, Col. Sheila Millette, NC, USAF.

18. Tel. interview, Col. David Hammer,

MC, USAF, Aug. 31, 2000. Col. Hammer,

formerly on on the staff of the AF surgeon

general, was the AFSOC surgeon during the

preparation for and execution of the Haiti

operations.

438

Notes