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Chain of Evacuation of Wounded Soldiers First World War
Explanation of the chain of evacuation and treatment of wounded soldiers during the Great War - guest article by Caroline Stevens, Editor of Unknown Warriors: The Letters of Kate Luard, RRC and Bar, Nursing Sister in France 1914-1918
The First World War created major problems for the Army's medical services. A man's chances of survival depended on how quickly his wound was treated. In a conflict involving mass casualties, rapid evacuation of the wounded and early surgery were vital.
Regimental Aid Post
The RAMC [Royal Army Medical Corps] chain of evacuation began at a rudimentary care point within 200-300 yards of the front line. Regimental Aid Posts [RAP's] were set up in small spaces such as communication trenches, ruined buildings, dug outs or a deep shell hole. The walking wounded struggled to make their way to these whilst more serious cases were carried by comrades or sometimes stretcher bearers. The RAP had no holding capacity and here, often in appalling conditions, wounds would be cleaned and dressed, pain relief administered and basic first aid given. The Regimental Medical Officer in charge was supplied with equipment such as anti-tetanus serum, bandages, field dressings, cotton wool, ointments and blankets by the Advance Dressing Station [ADS] as well as comforts such as brandy, cocoa and biscuits.
If possible men were returned to their duties but the more seriously wounded were carried by RAMC stretcher bearers often over muddy and shell-pocked ground, and under shell fire, to the ADS, sometimes via a Collecting Post or Relay Post to avoid congestion.
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Advanced Dressing Station
These were set up and run as part of the Field Ambulances [FA's] and would be sited about four hundred yards behind the RAP's in ruined buildings, underground dug outs and bunkers, in fact anywhere that offered some protection from shellfire and air attack. The ADS did not have holding capacity and though better equipped than the RAP's could still only provide limited medical care. Here the sick and wounded were further treated so that they could be returned to their units or, alternatively, were taken by horse drawn or motor transport to a Field Ambulance. The Main Dressing Station [MDS] roughly one mile further back did not at first have a surgical capacity but did carry a surgeon's roll of instruments and sterilisers for life saving operations only.
In times of heavy fighting the ADS would be overwhelmed by the volume of casualties arriving and often wounded men had to lie in the open on stretchers until seen to.
These were mobile front-line medical units for treating the wounded before they were transferred to a Casualty Clearing Station [CCS]. Each Army Division would have three FA's which were made up of ten officers and 224 men and were divided into three sections which in turn comprised stretcher-bearers, an operating tent, tented wards, nursing orderlies, cookhouse, washrooms and a horse drawn or motor ambulance. Later in the war fully equipped surgical teams were attached to the FA and urgent surgical intervention could be performed to sustain life. By the autumn of 1915 some FA's had trained nurses posted to them.
In these early stages men were assessed and then labelled with information about their injury and treatments. As in a casualty clearing station, medical officers had to prioritize using a procedure known as triage. Many of the wounded were beyond help; morphia and other pain killing drugs were the only treatment.
During Kate Luard's first year as a nursing sister in France and Belgium in WW1 she served on the ambulance trains until on 2 April 1915 she received movement orders to report to the Officer Commanding at No.4 Field Ambulance then located at Festubert. This brought her close to the front line and she referred to this in her diary as 'life at the back of the front'. Here she worked in close contact with an Advanced Dressing Station.
Casualty Clearing Station
These were the next step in the evacuation chain situated several miles behind the front line usually near railway lines and waterways so that the wounded could be evacuated easily to base hospitals. A CCS often had to move at short notice as the front line changed and although some were situated in permanent buildings such as schools, convents, factories or sheds many consisted of large areas of tents, marquees and wooden huts often covering half a square mile. Facilities included medical and surgical wards, operating theatres, dispensary, medical stores, kitchens, sanitation, incineration plant, mortuary, ablution and sleeping quarters for the nurses, officers and soldiers of the unit. There were six mobile X-ray units serving in the British Expeditionary Force [BEF] and these were sent to assist the CCS's during the great battles. CCS's were often dangerously vulnerable with large depots containing munitions and supplies alongside which were targeted by enemy aircraft and artillery.
A CCS would normally accommodate a minimum of fifty beds and 150 stretchers and could cater for 200 or more wounded and sick at any one time. Later in the war a CCS would be able to take in more than 500 and up to 1000 when under pressure. In normal circumstances the team would consist of seven medical officers, one quartermaster and 77 other ranks, a dentist, pathologist, seven QAIMNS [Queen Alexandra Imperial Military Nursing Service] nurses and non-medical personnel. Major surgical operations were possible but sadly, men who had survived this far often succumbed to infection. The CCSs were usually in small groups of two or three to enable flexibility: one might treat cases for evacuation by train, ambulance or waterways to the base area, leaving one free to receive new casualties and another was able to treat the sick who could be moved in order to receive battle casualties in an emergency.
Initially the wounded were transported to the CCS in horse-drawn ambulances - a painful journey, and over time motor vehicles or even a narrow-gauge railway were used. Often the wounded poured in under dreadful conditions, the stretchers being placed on the floor in rows with barely room to stand between them. The admissions and evacuations were incessant and almost all that could be done in the time was to feed the patient and dress his wounds. One of the greatest boons was the provision early in 1915 of trestles on which the stretchers were placed. Comforts such as sheets, pillow cases and bed socks were obtained from such organisations as the BRCS [British Red Cross Society]. As the number of casualties grew so the need for experienced staff increased. In the first Battle of Ypres difficulties were highlighted with an influx of between 1,200 and 1,500 casualties in twenty four hours and in the Battle of the Somme of July 1916 there were between 16,000 and 20,000 casualties on the first day of the offensive. By August 1916 selected CCS's had as many as twenty five nurses on the staff.
Gas was first used as a weapon at Ypres in April 1915 and thereafter as a weapon on both sides. Patients were brought in to the CCS suffering from the effects and poisoning of chlorine, phosgene and mustard gas among others.
The seriousness of many wounds and infection challenged the facilities of the CCSs and as a result their positions are marked today by military cemeteries.
Kate Luard was posted to a number of CCS's including one as Head Sister of No.32 CCS which specialised in abdominal wounds and which became one of the most dangerous when the unit was relocated in late July 1917 to Brandhoek to serve the push that was to become the Battle of Passchendaele, and where she had a staff of forty nurses and nearly 100 orderlies.
From the CCS men were transported en masse in ambulance trains, road convoys or by canal barges to the large base hospitals near the French coast or to a hospital ship heading for England.
These trains transported the wounded from the CCS's to base hospitals near or at one of the channel ports. In 1914 some trains were composed of old French trucks and often the wounded men lay on straw without heating and conditions were primitive. Others were French passenger trains which were later fitted out as mobile hospitals with operating theatres, bunk beds and a full complement of QAIMNS nurses, RAMC doctors and surgeons and RAMC medical orderlies. Emergency operations would be performed despite the movement of the train, the cramped conditions and poor lighting. Hospital carriages were also manufactured and fitted out in England and shipped to France.
In the early trains there was often a lack of passage between the coaches and with only a few nurses it was necessary for a nursing sister to pass from coach to coach, whether the train was in motion or not, usually carrying a load of dressings, medicines etc. on her back in order to tend to the wounded on each coach. During the night she also had a hurricane lamp suspended from her arm. The medical staff consisted of three medical officers of the RAMC including the Commanding Officer, usually a major, two lieutenants, a nursing staff of three or four with a sister taking on supervision of the whole train, complemented by 40 RAMC other ranks and NCO's [non-commissioned officers].
An average load was 4-500 patients with a large number in critical condition. Often they were transferred to the train still in full uniform in shocking condition caked with mud and blood and owing to the cramped conditions their uniforms had to be cut away. Many journeys were long such as the one from Braisne to Rouen taking at least 2 ½ days. There were deaths on all journeys. The nurses' workload was heavy and they worked under dangerous conditions with the barest necessities and no comforts.
In Kate Luard's first book published anonymously in 1915 she vividly describes in her letters home her experiences working on the early ambulance trains 1914-1915 transporting wounded soldiers back from the Front to hospitals in the base area.
Many wounded were transported by water in hospital barges. Although slow, the journey was smooth and this time allowed the wounded to rest and recuperate. The barges were converted from a range of general use barges such as coal or cargo barges. The holds were converted to 30 bed hospital wards and nurses' accommodation. They were heated by two stoves and provided with electric lighting which would have to be turned off at night to avoid being an easy target for German pilots. Nurses would have to make their rounds in pitch dark using a small torch. Outside the barges were painted grey with a large red cross on each side with the flag poles flying the Red Cross to signify they were carrying wounded soldiers. The interior was painted white with ventilators in the side roofs and later skylights built in to the barge. There would normally be at least one QAIMNS sister, a staff nurse and RAMC orderly per barge but with a full load of patients an RAMC sergeant, corporal, three nursing sisters, two orderlies, a cook & cook's assistant. The skipper of each barge was usually a Royal Engineer [RE] sergeant and the barge would be towed by steam tugs.
As the war progressed many soldiers were evacuated straight onto the barges from the trenches and battlefield and were ridden with lice and filthy. Due to the lack of ventilation there were problems with gas attacked patients with the smell of gas remaining on their clothing and breath which caused sickness, sore eyes and breathing problems to the nurses and patients.
Kate Luard mentions hospital barges on many occasions and in May 1915 she assists the staff on a RAMC barge which was packed with all the worst wounded in blood- soaked clothes - two died and more were dying.
Stationary Hospitals, General Hospitals and Base Area
Under the RAMC were two categories of base hospital serving the wounded from the Western Front.
There were two Stationary Hospitals to every Division and despite their name they were moved at times, each one designed to hold 400 casualties, and sometimes specialising in for instance the sick, gas victims, neurasthenia cases and epidemics. They normally occupied civilian hospitals in large cities and towns, but were equipped for field work if necessary.
The General Hospitals were located near railway lines to facilitate movement of casualties from the CCS's on to the coastal ports. Large numbers were concentrated at Boulogne and Étaples. Grand hotels and other large buildings such as casinos were requisitioned but other hospitals were collections of huts, hastily constructed on open ground, with tents added as required, expanding capacity from 700 to 1,200 beds. At first there was a lack of basic facilities - no hot water, no taps, no sinks, no gas stoves and limited wash bowls. The staff establishment was normally thirty four medical officers of the RAMC, seventy two nurses and 200 auxiliary RAMC troops.
Some general hospitals were Voluntary Hospitals supplied by voluntary organisations, notably the Red Cross and St John's Combined Organisation who ran one at Étaples. In the base areas such as Étaples, Boulogne, Rouen, Havre and Paris, the general hospitals operated as normal civilian hospitals with X-ray units, bacteriological laboratories etc. The holding capacity was such that a patient could remain until fit to be returned to his unit or sent across the channel in Hospital Ships for specialist treatment or discharge from the forces. Some of the general hospitals were handling the treatment of patients until well into 1919; in March 1920 there were still four active medical units in France - one General Hospital, one Stationary and two CCS's.
Within months of the Americans entering the war in 1917 the medical assistance they had promised the BEF [British Expeditionary Force] began to arrive in France and the first units took over 6 British General Hospitals.
Although for most of the WW1 Kate Luard served on the Ambulance Trains, in Casualty Clearing Stations and a Field Ambulance- intermittently she worked in various Stationary and General Hospitals in the base area.
Hospital Ships and Military and War Hospitals at home
Most hospital ships were requisitioned and converted passenger liners. Despite the excellent nursing and medical care many patients died aboard because of their extreme wounds. The risk of torpedoes and mines as they crossed the channel was very real.
On arrival at a British port the wounded were transferred to a home service ambulance train and on to Military and War Hospitals which were divided into nine Command areas.
Not included are numerous people and organisations who were also involved in the evacuation chain. The nursing staff were supplemented by trained BRCS (British Red Cross Society) nurses and by volunteers of the Voluntary Aid Detachment (VAD's). The VAD's worked in the general hospitals and in the last two years of the war in stationary hospitals. In the early days of the war there was a Red Cross train and No.16 Ambulance Train was staffed by the Friends Ambulance Unit. The VAD's with trained Red Cross nurses were also employed right through the war on many railway stations and provided food, drinks, comforts and some first aid facilities.
Many thanks to Caroline of www.kateluard.co.uk for this guest article.
RAMC in the Great War: 'The RAMC Chain of Evacuation' www.ramc-ww1.com
Making the Modern World - World War One 'Processing the Wounded on the Western Front' www.makingthemodernworld.org.uk
The treatment of Wounded and Sick Soldiers; The Great War 1914-18: 'The Evacuation Chain' www.ramsbottomwarmemorialproject.co.uk
QARANC (Queen Alexandra's Royal Army Nursing Corps) 'Ambulance Trains', 'Hospital Barges' 'Hospital ships' www.qaranc.co.uk
www.scarletfinders.co.uk an excellent reference for all aspects of nursing, ambulance trains and casualty clearing stations in the Great War
Susan Cohen, Medical Services in the First World War. Shire Books, 2014
Christine Hallett, Containing Trauma: Nursing Work in the First World War. Manchester University Press, 2009.
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