 The end product of war, regardless of whether conventional or nuclear weapons are employed, is always the same from the medical point of view. One moment, the healthy individual, the next, the patient. Results of battle, the wounded, the injured, the dying, and the dead. Not all the casualties are among the men who fight. Medical personnel, because of their close support of combat troops, share the same hazards. To provide patients with the best possible medical care under combat conditions requires a medical system specifically designed to function in a battlefield environment. To meet this need, the Army Medical Service has developed a set of principles which form the foundation for medical practice in the field. In this film, we're going to discuss these principles. But first, I'd like to illustrate for you the overall concept of military medicine in a combat situation. Now, all of you I know are familiar with the traditional type of civilian hospital. Here, for economy and convenience, all of the essentials of a total medical practice are grouped together. When a civilian becomes ill or injured, he receives first aid from ambulance personnel and is transported to a hospital. In the receiving department, doctor examines him and initiates treatment. Within the hospital itself are all of the services required to complete treatment of the patient. All of the medical services of this system are also present within the field medical service of the United States Army. However, they are divided into phases in a linear distribution reaching from the forward edge of the battle area back to permanent hospitals, hundreds, perhaps thousands of miles from the scene of combat. In general, the military system works like this. When there is a casualty, an aid man initiates emergency medical treatment as soon as possible and then a littered team normally carries the patients to a collecting point where an ambulance evacuates them to the first medical treatment facility. This treatment is equivalent to the first aid and ambulance service of a civilian medical system. The aid man makes certain the patient can breathe, stops bleeding, dresses wounds, combat shock, splints fractures, and prepares them for evacuation. Normally, litter teams are used to clear patients from the battlefield. The combination of aid man and litter team is equivalent to the first aid and ambulance of a civilian medical system. Under combat conditions, however, litter teams may not always be available. In such situations, patients must be evacuated by the most appropriate means of hand, no matter how primitive. Patients are moved to an aid station comparable to a hospital receiving department. The aid station is a small, mobile treatment facility located within the combat area. This is the first level of medical service at which a doctor is present. Here in the aid station, patients are examined, treated, and either returned to duty or prepared for further evacuation. The primary mission of the medical officer in the aid station is to treat and return to duty the less serious cases and to provide sound emergency or resuscitative care in more serious cases requiring further evacuation. Depending on the treatment required, patients will be evacuated either to a division clearing station or to a surgical hospital. The clearing station provides more elaborate medical care of patients than the aid station. The surgical hospital, which is comparable to emergency surgery of a civilian hospital, provides resuscitative surgical and medical treatment. These two units are located in the forward area of the combat zone. At the clearing station, patients are sorted. Some are treated and returned directly to duty. Others, requiring relatively simple treatment, are retained for short periods before being returned to duty. The rest are given appropriate treatment and then evacuated farther to the rear. The surgical hospital is the most elaborate medical unit found in the forward area. Its mission is to provide prompt surgical treatment which should not be delayed. 100% mobile, the surgical hospital is designed to move as required in order to keep abreast of the tactical situation. When patients reach the evacuation hospital, they are stirred by a well-equipped surgical and medical staff. Father from the scene of combat, the evacuation hospital is a semi-mobile installation usually located near rail and air transportation facilities. Patients received in the evacuation hospital are again subjected to triage, the process of sorting to decide whether they should be treated and returned to duty, held for further treatment, or evacuated. Those patients evacuated to a numbered general hospital receive the same care that would be available in any large modern civilian hospital. The numbered general hospital is a fixed facility capable of providing treatment in all medical and surgical specialties. And finally, patients may be evacuated to large army hospitals within the zone of the interior for prolonged medical treatment or extended convalescence. This then is the basis of the field medical service, a total medical system divided into levels or phases, reaching from the forward edge of the battle area back to the zone of the interior. Alright, now let's take a look at the principles upon which the field medical service is based. The first, and perhaps most important of these principles, is continuity. Once an individual becomes a patient, he must be supported medically without interruption until physiologic stabilization is reached and health is restored. Medical care must be continuous, not only at each level or phase of treatment, but must continue even during periods of evacuation from one treatment facility to another. In fact, the care and treatment of patients during movement and the timeliness of movement are critical aspects of continuity. There are many considerations which must be kept in mind by medical personnel if they are to ensure that the continuity of patient treatment is not interrupted. In the excitement and confusion of a complicated and constantly changing battlefield environment, medical procedures must be simple and standardized at each level of the phase system of medical service. To facilitate this, the same levels receive the same medical supplies and equipment. There is no point in transporting equipment for brain surgery up here at the forward edge of the battle area where only emergency or basic resuscitative treatment can be given. Standardized medical procedures at each level help assure continuity of patient treatment and care. Medical officers must always recognize the realistic limitations built into the phase system of treatment imposed by the combat situation and must not be permitted to attempt procedures beyond the capabilities of the level of treatment to which they have been assigned. Attempts at overly ambitious procedures almost invariably work to the detriment of patients. Combat medicine requires simple, prompt, and appropriate measures. It has been shown over and over again that the best method of handling combat casualties is for each unit to perform those procedures for which it is designed and then has required to evacuate patients to levels of medical service designed to provide more elaborate care. To reinforce continuity of care at every level triage takes place. Accuracy and sorting requires good professional judgment. The battle-trained soldier is difficult to replace. Under combat conditions it is extremely important that patients be returned to duty as quickly as possible. Some patients with minor wounds, for example, will be held in this aid station for additional treatment. They will be cared for here and then returned directly to their organizations. Similarly, many patients suffering from the stresses of combat can best be treated far forward in the combat zone. Good medical judgment and sorting can do much to protect combat forces from unnecessary manpower losses. Patients should not be moved farther to the rear than that point where they can receive adequate medical care. When evacuation is necessary to assure continuity of care and treatment, the supporting level of medical service is responsible for the evacuation of patients from forward medical facilities. Evacuation support comes from the rear. At a second level battlefield clearing station, for example, ambulances from the third level of medical service must always be on hand. As one is loaded and moves away, another moves up to receive more patients. In this way, a constant and automatic system of evacuation relieves the clearing station of congestion and possible immobilization. Simple standardized procedures, proper sorting and constant evacuation from the rear all works together to assure continuity of patient care and treatment. Our next principle is that of control. Management of patients, of course, is a medical responsibility. Therefore, once within medical channels, patients must remain under the control of a staff surgeon or medical commander. This requires that the medical service control the means by which patients are moved as well as treatment facilities themselves. If control of patients is lost, continuity of patient treatment is lost as well. Medical means are never unlimited and must be used economically to ensure that a maximum number of patients receive care. Except in rapidly changing, retrograde or independent operations, control should be as centralized as possible. Through standardization and control, treatment is similar within each level. Thus, each medical unit will be able to carry out its assigned mission and patients will be evacuated in good condition to the next level of treatment. The phased system of treatment is designed to overcome the limitations imposed by the battlefield environment. It is not intended to regiment professional skills, but rather to ensure the realistic practice of battlefield medicine. Nor is it intended to confine evacuation and treatment within inflexible channels which cannot be offered to fit changing circumstances, but rather to ensure that adequate medical service will be available for all who may need it. It is of course the desire of everyone to provide in combat the quantity and quality of medical care each of us expects in peacetime. War produces patients in great numbers in a short period of time. When these exceed the existing medical capabilities, the available medical assets must be distributed so as to provide the greatest service to the greatest number. Supplies and equipment must be apportioned to meet the requirements of the overall situation and must be expended judiciously. Whenever mass casualties occur, it is up to the medical personnel to take appropriate, timely measures for the majority of the patients before beginning the time consuming, detailed procedures required for a few. In view of the emotional response to suffering, it is not easy to think of treating patients in this way. However, a handful of men may mean the turning point in a combat situation. For the best medical practice in the battlefield environment, patients, equipment, means of movement, apportionment of medical capabilities should be under medical control. Our next principle is that of proximity. Similarly, unlike material objects which once damaged remain in the same condition for extended periods of time, the human machine once damaged does not remain static but follows a predictable course of deterioration if medical treatment is not initiated properly. In order to achieve the lowest rates of morbidity and mortality, effective treatment must be initiated as early as possible, preferably within the first few hours after wounding. Therefore, medical units must be located as close as possible to the scene of combat. This principle of proximity applies particularly to the aid man, the aid station, and to those levels of medical support essential to the resuscitation of patients. When it becomes impossible to establish forward treatment facilities as near to the combat area as desirable, the deficit must be made up by increasing the emphasis on rapid evacuation. Prompt clearing of the battle area will ensure patients are brought to where they can receive treatment early and also will provide the rest of the group with the assurance that they too can expect effective medical support in the event they become casualties. Remember, proximity is a factor of both time and distance. Our next principle, flexibility, is a basic principle of war. For medical personnel, this means essentially keep a reserve. The function of the medical service is to support combat forces. Medical units, personnel and means must be available to meet changes in the tactical situation, which may occur suddenly and without warning. Once a medical unit is in place in the field and is treating patients, it is difficult to make a change in its location until the patients are evacuated. When a medical reserve exists, the system has flexibility and treatment facilities can move to support changes in the tactical situation. In order to maintain maximum flexibility, only the necessary medical means for the task at hand should be committed. Another basic principle of war is mobility. Medical units must have the same mobility as the units they support. The method of movement may vary. Medical units support ground and amphibious assaults and accompany airborne operations. The medical service must never fall behind. Mobility, however, has another meaning for medical installations. A patient handling facility cannot move until its responsibility to its patients is completed. Thus, a medical unit might have the needed transportation to move and yet be unable to do so because of the patient load. Therefore, to retain mobility, the treatment and evacuation of patients must be prompt and continuous. The medical commander must ensure that medical means are distributed on the battlefield so as to support areas of expected casualty density. If an attack is to be made on one sector while other sectors remain on the defensive, medical facilities must be distributed so that extra support will be available in the area of attack. However, this type of emphasis cannot mean neglect of other areas. It simply means using inherent mobility in order best to support combat troops. The sixth principle is that of conformity. Adherence to the principle of conformity is fundamental in the design of an effective military medical service. The mission of the field medical service is, of course, to support combat troops. When a military operation is being planned, the medical commander must study the tactics and concepts of the tactical commander's plan. If the tactical commander intends to attack to the west, medical units must obviously be prepared to support the attack in that direction. The medical commander and his staff must study both the main plan and the alternate plans being considered by the tactical commander and develop a medical plan to support all aspects of the combat operation. Whatever the demand of the combat situation, regardless of whether the operation is to be on land, across water, or by air, medical units must adapt themselves to the situation and conform to it. During the execution of a military operation, medical means must be employed so as to be timely and adequate. They must not hinder the operation. Medical service should always be unobtrusive and complementary. When medical planning conforms to tactical planning, the right medical means will be available at the right time, in the right amount, and in the right place. These, then, are the six principles of field medical service. Once treatment of a patient has begun, it must be continued without interruption. Adequate treatment combined with timely evacuation support from the rear can assure the continuity of patient care at and between each phase of the medical system. Patients and the means to treat them must remain under the control of medical personnel at all times. In this way, each medical facility will be able to carry out its mission and the greatest good to the greatest number will result. Battle area medical units must be close enough to supported troops to be able to initiate treatment of casualties promptly. Proximity is a factor of both time and distance. The medical service in the field must always retain enough flexibility to be able to adjust to rapid changes in the tactical situation and must possess sufficient mobility to keep up with the units it is supporting. Over, medical means and facilities must be properly distributed through the combat zone. Finally, there must be conformity on the part of medical units to the plans and operations of the tactical commander. Adherence to these principles in a combat environment will assure the lowest rates of mobility and mortality, the earlier return of the fighting man to his unit, the efficient utilization of available medical means, and the best care and treatment of battlefield casualties. For these principles have evolved out of hundreds of battles and millions of patients as the medical service has carried out its mission to conserve the fighting strength.