“Over the centuries one simple principle has remained: Get the casualty off the battlefield and into the hands of a surgeon as fast as possible.”

By Adam Staten

FOR AS LONG as people have fought wars, there has been a need to evacuate and treat wounded soldiers, a process widely known today as “casevac.”

Systems of care for wounded soldiers appeared very early in human history. Evidence from papyri shows that the ancient Egyptians had a good knowledge of treating battle wounds as early as 1600 BCE and that they deployed physicians and surgeons to military garrisons to maintain the health of their fighting forces. The Babylonians however were probably the first to employ full-time military surgeons by about 1000 BCE. Of course, the military medics par excellence of the ancient world were the Romans.

The Roman approach to casualty extraction and treatment was as well thought out as all other aspects of their military machine. Battlefield first aid was practiced at the front line, and casualty collection was organised based on the legion system. In fact, the speed and efficiency with which Roman armies delivered treatment to wounded soldiers ended with the fall of the empire and wouldn’t be matched again until relatively recent times.

During the medieval period there were haphazard efforts to care for casualties. The army of Philippe le Bel in 13th Century France counted barber surgeons among its ranks, and Henri II of France actually set up mobile hospitals in 1550. Despite these measures, in general, wounded soldiers were largely left to fend for themselves in the Medieval period. Nobles might have access to personal physicians, or at least they’d have servants to drag them from the battlefield. The common soldier however had to rely on his mates, or on the fickle mercies of those local people who arrived to loot the battlefield once the fighting ended.

If casualty evacuation is seen as the means by which a wounded man is most quickly delivered to a capable surgeon, then the medieval indifference to casevac really just reflects the general state of medical care at that time: there was hardly any point getting a casualty to a surgeon because at the time there was so little that could be done for hacked and cleaved bodies.

It was really in the late 18th and 19th centuries when casualty evacuation began to take on a form that we might more readily recognise today.

Many consider the father of modern military medicine to be Dominique Jean Larrey. Larrey was a pioneering battlefield surgeon who served on every one of Napoleon Bonaparte’s campaigns. Not only did Larrey pioneer numerous new surgical techniques, but he also devised a system of triage (the French word for ‘picking’ or ‘sorting’) based on the severity of their injuries, regardless of rank or status. He also recognised the importance of rapid casualty extraction.

Larrey created the ‘ambulance volante’ (flying ambulance) – a carriage drawn by two horses that could speed to the battlefield to collect wounded soldiers and carry them to the dressing stations of the era. He also adapted his casualty evacuation plans dependent on what was on hand during the campaign. For example, he evacuated 150 casualties from the Battle of Bautzen in wooden wheelbarrows that were commandeered from local inhabitants. This need to adapt casevac plans to local conditions persists to the modern day.

During the peace following the Napoleonic Wars, medical knowledge kept pace with the general scientific advancements of the age making great leaps forward. Ironically, the transfer of this new learning to the battlefield during the next major conflict, the Crimean War, was patchy.

The Russian surgeon Nikolay Pigorov further refined the concept of triage to divide casualties into four main categories from the walking wounded to those who were beyond saving. His method broadly survives today. In addition to experimenting with anesthetics in the field, Pigorov also used nurses from a newly created order of nurses to perform the triage, thereby freeing up surgeons and increasing the efficiency of field hospitals.

On the British side, Florence Nightingale quite literally shone a light on the enormous deficiencies in British military medical care. The government review precipitated by Nightingale’s revelations eventually led to the creation of the Royal Army Medical Corps in 1898 along with properly laid out plans for casualty evacuation and treatment.

These plans were immediately put to the test during the Boer War. Here, each regiment had a ‘Regimental Aid Post’ consisting of a medical officer, two orderlies and a team of stretcher bearers. This team could deliver immediate battlefield first aid before the casualty was evacuated to a field hospital for emergency surgery, such as amputation or wound dressing. Then the ‘Hospital Train’ (a system of horse- or oxen-drawn carts specifically tasked with evacuating wounded men) would take casualties onto a larger hospital for more definitive treatment and convalescence. Although this system has evolved and been adapted since the Boer War, it is fundamentally the same one used by the British Army today.

The First World War presented new and unprecedented challenges to military medicine. Just as the conflict was a catalyst for other martial technology, so it was for military medicine. Motorised ambulances were widely used for the first time, and even the basic aircraft of the era were occasionally pressed into service to transport casualties. The various theatres of war also required an adaptability of planning of which Larrey would have been proud, including the use of donkeys in Gallipoli and camels in the desert.

The use of aircraft in casualty evacuation is ubiquitous now and the limited lessons in the use of aircraft in the Great War were rapidly built upon. As early as 1923 a mass aeromedical evacuation of 200 dysentery cases was conducted by British forces in Iraq.

Helicopters – now the staple vehicle for casevac – were used experimentally during the Second World War. They would become standard in the Korean War and beyond.

The helicopter’s ability to land in difficult terrain and urban environments, to carry a medical team on board, and to travel rapidly across long distances, means that they remain unsurpassed as a means of getting wounded men and women away from the battlefield.

In recent years, during the conflicts in Afghanistan and Iraq, survival rates among allied soldiers with catastrophic injuries were astonishingly high. These survival rates were made possible by highly efficient evacuation chains that were built on 200 years of learning and experience. Yet over the centuries one simple principle has remained: Get the casualty off the battlefield and into the hands of a surgeon as fast as possible.

is the author of Steadfast: Band of Brothers, a novel about the War in Afghanistan. A doctor in the UK, he previously served as a medical officer in the British Army. The book, Staten’s first, is based on his experiences serving alongside the Grenadier Guards in Helmand Province, Afghanistan. For more information visit his webpage at www.adamstaten.com.