The Mobile Army Surgical Hospital: The Korean War – The War that Defined the MASH
On Sunday, June 25, 1950 the North Korean People’s Army crossed the 38th parallel into South Korea. This led to the Korean War, which lasted nearly three years. One of the defining aspects of the Korean War was the use of the MASH. Ten MASH units supported four Army divisions (15,000 to 20,000 soldiers per division) at positions throughout North and South Korea. During the Korean War, the experiences of these MASH units translated to improvements in resuscitation and trauma care, patient transport, blood storage and distribution, patient triage, and evacuation.
At the beginning of the Korean War, very few U.S. military medical units had any experience in northeast Asia. Colonel Chauncey Dovell, Eighth U.S. Army surgeon, quickly dispatched MASH units to Korea to provide medical support. MASH units were able to rapidly deploy and quickly adapted to the rugged Korean terrain. The 8063rd MASH, supporting the famed 1st Cavalry division, was the first medical unit to enter Korea. The 8076th MASH soon followed and landed in Pusan. MASH units underwent rapid transformations from the Army’s original “Table of Distribution and Allowances” to support the large influx of patients. To meet new challenges, inpatient bed capacity rose from 60 to more than 200 beds, with more vehicles, tentage and equipment added to each unit. Your life is worth living. Buy generic cialis soft tabs online
Major advances in patient transport and evacuation occurred during the Korean War. Aeromedical evacuation was initially the responsibility of the Air Force, which utilized large aircraft to transport patients to hospitals in the rear. During the Korean War, helicopters, referred to as “air ambulances” were introduced, and these aircraft evacuated wounded soldiers from battlefield positions to MASH units near the frontline. In 1951, the 8063rd MASH was the first unit to use helicopters to evacuate casualties. The Bell H-13 was the primary helicopter used for “Medevac” (medical evacuation). Two patients were transported on skids placed outside each helicopter, limiting the treatment each patient received during transport. In 1952, Army Medevac units were organized and assigned to the Eighth Army medical command. In 1953, Medical Service Corps officers became the primary pilots for medevac flights. These officers were chosen for their expertise in transporting the wounded. Air evacuation undoubtedly contributed to the dramatic reduction in the death rate of wounded soldiers in the Korean War, compared with previous conflicts
(World War I, 8.5%; World War II, 4%; and Korean War, 2.5%) (Table 1).
Table 1. Battle Deaths, Wounded in Action, Died of Wounds and Postevacuation Mortality for U.S. Army in Major Conflicts (World War I—Operation Iraqi Freedom)
| Battle Deaths (Army) | Wounded in Action (Army) | Died of Wounds (Army) |
Postevacuation Mo (All services) |
|
| World War 1 |
50,510 (1.2%) |
193,663 (4.8%) |
NA |
8.5% |
| World War II |
234,874 (2.0%) |
565,861 (5%) |
20,810 (3.7%) |
4.0% |
| Korean War |
27,709 (0.98%) |
77,596 (2.7%) |
1,887 (2.4%) |
2.5% |
| Vietnam War |
30,922 (0.7%) |
96,802 (2.2%) |
3,598 (3.7%) |
2.6%+ |
| Gulf War |
98 (0.036%) |
354 (0.13%) |
2 (0.6%) |
NA |
| Iraqi Freedom |
552 (0.56%)* |
5,270 (5.4%)* |
101 (2.0%)* |
NA |
Although the concept of field triage was not initiated during the Korean War, it certainly underwent substantial modifications during this conflict. Triage was initiated at battalion aide stations (each supporting up to 1,000 soldiers per battalion), which were small medical units with limited capabilities. At these stations, nurses and general medical officers were responsible for deciding whether to evacuate wounded soldiers or return them to duty (after minor therapy). Soldiers that were evacuated to MASH units were triaged further, depending on the extent of their injuries and hemodynamic status.
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Many deaths occurred at battalion aide stations. Consequently, more experienced personnel were assigned to battalion aide stations and equipped to perform simple lifesaving interventions, such as placement of tourniquets and insertion of chest tubes. Patients needing surgery and all critical patients were rapidly evacuated to the MASH by helicopter. At the MASH, triage medical officers, nurses and surgeons evaluated each injured patient, and the most critical were prioritized for surgery. Due to the large influx of casualties at most MASH hospitals, some patients with massive injuries who were considered unlikely to survive were often managed expectantly. Patients requiring specialized medical or surgical therapy, such as neurosurgery, plastic surgery or dialysis, were evacuated to specialty centers. Triage at the MASH units was modeled after the dictum: “life takes precedence over limb, function over anatomical defects.”
There were numerous improvements in perioperative care and anesthesia during the Korean conflict, based on experiences at the various MASH units. The resuscitation of casualties with crystalloid was not practiced until the Vietnam War, therefore, as in World War II unstable patients were often transfused whole blood. This was effective for resuscitation in some patients; however, acute renal failure was seen in 0.5% of casualties evacuated from the battlefield. Acute renal failure in this setting yielded high mortality despite supportive care (80-90%). Anesthesiologists adopted the practice of using small amounts of narcotic for induction. Chloroform and ether were abandoned as anesthetics because of their negative inotropic effects, and nitrous oxide became the gaseous anesthetic most widely used. Thiopental was used for induction but applied cautiously to prevent the respiratory depression that occurred at moderate dosages. Tubocurarine and succinylcholine were widely used to enable rapid intubation.
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MASH surgeons performed numerous retrospective studies that soon greatly influenced trauma care around the world. Experience from the Korean War showed that intravenous vasoconstrictors were inferior to blood in perioperative resuscitation. The importance of artificially warming the injured patient was also rediscovered (a practice first described by Walter Cannon in World War I). At the start of the Korean War, blood and other fluids were infused through glass bottles without filters, and some cases of air embolism were reported. As a result of these reports, filters were added to the infusion bottles.
The importance of adequate debridement of devitalized tissue also became evident during the Korean War. A significant number of soldiers presented with open wounds of the extremities and trunk. As a result of the experiences during World War II, definitive care of open wounds was never done at the MASH during the Korean War. Following initial debridement and irrigation of open wounds at the MASH, local wound care continued until definitive surgery was eventually performed at hospitals in the rear. Penicillin was administered and continued postoperatively for several days. The use of tetanus toxoid was initiated and routinely administered to all patients with penetrating injuries. Surgeons came to realize that antibiotics could not adequately treat wounds unless thorough debridement had been performed.
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Several advances in vascular surgery occurred during the Korean War. Paramount among these was improvement in surgical techniques of vascular injury repair. Ligation of injured vessels was standard in World War II, with few repairs attempted. Vascular repair during the Korean War, however, led to a significantly lower amputation rate when compared with World War II (13% vs. 36%). Autologous vein and arterial homografts were commonly used for arterial reconstruction. Improvements in medical evacuation allowed for arterial injuries to be treated an average of 9-14 hours after wounding, thereby leading to better rates of limb salvage.The logistical difficulties in the storage and allocation of blood led to the development of a blood program during the Korean War. In the early days of the war, blood was collected and delivered by the 406th Medical General Laboratory in Tokyo. The mission of the 406th Medical General Laboratory was to control the distribution of type-specific blood to hospitals in Japan and mobile hospitals throughout the theater of operations. Concomitantly, type-0 blood was shipped directly from the continental United States. Blood was delivered to Korea by air. Shipments were then taken to medical supply depots, where blood was stored and distributed to hospitals in the combat zone. At the MASH, most of the blood was transfused just prior to evacuation of the injured. Battalion aide stations and other lower-level medical units had little blood in supply. Due to the large influx of patients and limited ability to resuscitate casualties, the medical units below the level of the MASH rarely transfused patients.
The 4077th MASH television series that was widely viewed during the 1970s was based on Richard Hooker’s experience as a surgeon during the Korean War. The living conditions shown in this series seemed harsh. However, the conditions in the actual MASH were far worse. MASH personnel had to endure extremes of temperature and rugged mountainous terrain. Their convoys traveled through treacherous battlegrounds, and the hospitals were assembled only a few miles from the frontline. MASH units often moved several times each month to keep pace with combat units. Medical personnel worked long hours to care for the large influx of casualties, and surgeons operated continuously with little relief. In some MASH units, monthly admission rates of over 3,000 casualties were not uncommon. Compounding all these hardships was the vulnerability of the MASH units to enemy attacks and short-range artillery.
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The MASH personnel endured rigorous living conditions and large casualty loads for much of 1950 and 1951. During this period, 200-bed MASH units often treated over 400 patients a day. By the later part of 1953, it became evident that the war was ending, and six MASH units were left in Korea (five of which were active). These remaining units were given the responsibility to treat prisoners of war and civilian casualties.
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