Air medical transport: “Hot Air” and a French lesson

CLINICALREPORT

Air Medical

Transport: "Hot Air" and a French Lesson •

A n d r e w J. Macnab, MD, FRCP(C)

THE 75TH ANNIVERSARY OF THE FIRST

air medical transport of a military patient occurred on November 16, 1990.1 The first known air medical transport occurred during the retreat of the Serbian Army from Albania in 1915, when it proved impossible to evacuate w o u n d e d of the F r e n c h Expeditionary Force by conventional m e a n s . 1-3 A F r e n c h m a n , Captain Dangelzer, 1,2,5 evacuated Lieutenant Stefanik1,3 of the Serbian Air Force, who was w o u n d e d and v o m i t i n g blood.l, s This first air medical transport flight during hostilities was 80 km long 1,3,6 and took place in an unmodified F r e n c h f i g h t e r aircraft 2-4,7,8 (Farman F-Vb).I During the same month, this patient was flown a further 250 km 1 by Lieutenant Panlhan, 5 and five other pilots evacuated 12 other wounded individuals by air. 1,3,7 For those readers who are familiar with the literature on air medical transport, the fact that this event represents the first air medical evacuation will come as a surprise. The existing literature, while containing many good studies and reviews, con7..sistently perpetuates a notable error. The actual origins of air medical transport are unrecognized, probably Andrew J. Macnab is medical director of the Pediatric Transport Program at the British Columbia Children's Hospital in Vancouver, British Columbia.

b e c a u s e of an early e l e m e n t a r y error in translation from the French. All of the recent literature concerning the history of air medical transport r e f e r s to a much earlier historical event as the origin and first i n s t a n c e of air m e d i c a l evacuation. 1'2'9-21 T h e quote f r e q u e n t l y runs as follows: "Aeromedical transportation w a s introduced in 1870 during the FrancoPrussian War when 160 casualties were evacuated from the siege of Paris by hot-air balloons." However, F r e n c h descriptions of t h e s e Figure 1. The Neptune, the first military postal balloon events clearly doc- to fly out of Paris during the Siege. Note the pipe runu m e n t that there ning to the ballon. are t h r e e fundamental errors in these reports: (1) some w e r e "bless6," i.e., injured as a these were not hot-air balloons; (2) r e s u l t of t h e s e flights. 2224 The 166 individuals (not 160) were F r e n c h word " b l e s s e r " m e a n s to involved; (3) all of them were unin- injure or to wound. In all probability jured when they left Paris, although an early incorrect translation led to

The Journal of Air Medical Transport ° August 1992

15

the i n f e r e n c e that t h e s e flights involved the already wounded, and may have contributed to the other inaccuracies. The publications misrepresenting the balloon flights from Paris 13,921,z5 all refer back to a small number of r e f e r e n c e s . Five 9,11,12,18,25 ultimately refer back to one of two source references, 2,26 one of which gives no reference for the events quoted, 26 one of which is an u n r e f e r e n c e d paper, 2 three of which 13,15,16 cite references that do not mention the flights. 4,2729 Three cited references26,3°,31 do contain the qualifier that the evacuation of patients "is believed" to have begun during the siege of Paris, but the "is believed" is omitted when they are requoted. 9,12,14,19 Sixty-six manned balloon flights did in fact occur d u r i n g the siege, z2,2a,a2 However, the concept that 160 wounded were evacuated by hot-air balloons is c h a r m i n g but implausible. Would a city such as Paris, under siege, full of the rich and infamous, with up to 4671 of its

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inhabitants dying each week, 22 really set about evacuating 160 of its w o u n d e d soldier class? If so, to where? Review of the documented passengers, flight routes, and fate of each balloon flight shows, not surprisingly, that the direction of the flights was totally at the whim of the wind, and that the balloons ultimately landed in a 360-degree radius around Paris. Several balloons were lost into the sea, and one flight, the longest (1246 km), ended in Norway. z2,33 It is unlikely, therefore, that the purpose of the flights was to evacuate the wounded to better medical facilities, as stated in two references. 9,12 The actual purpose of the balloon flights was primarily to carry messages and to t r a n s p o r t c a r r i e r pigeons, which were then used for return of intelligence reports. In this regard, the flights were innovative and highly successful. 22,a2 Military personnel were involved in these flights, mainly as volunteers or volunteered pilots from the Marine Corps. The majority of p a s s e n g e r s were

from among the politically significant or militarily expedient and travelled for state or intelligence reasons. 22'23 Disused railway stations were used to house the balloons during manufacture, and the gare d'Orleans, the gare du Nord and the Place SaintPierre (below the present-day Sacr6Coeur) w e r e the major lauflch sites, ze,z3 It is a great tribute to the pioneers of French aviation present in Paris at the time that they not only conceived this means of communication, but also were able to manufacture the number of balloons involved and launch them effectively under a state of siege. Two recent French reviews of the original flight records and correspondence from the time indicate that the number of individuals who flew from the city as pilots or passengers was not 160, but 166.22,23 Not all of them survived. M a n y flights s u f f e r e d mishap, and deaths occurred due to direct injury and the rigours of the flight. At least 16 balloons crashed during landing; 9 flights document

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T h e J o u r n a l of Air M e d i c a l T r a n s p o r t • A u g u s t 1992

significant injury to p a s s e n g e r s or pilots, and 3 describe environmental injuries, mainly from the cold. Two pilots died when balloons were lost into the sea. 22,23Two deaths occurred following flights, one marine died of smallpox eight days after flying, and another individual died of tuberculosis aggravated by injuries incurred during a crash landing. 24 T h e latter is known to have b e e n suffering from the disease before being flown from Paris, and his illness had nothing to do with his decision to fly. Many balloons were shot at by the Prussians using s t a n d a r d rifle fire. T h e Prussians also developed a special gun intended to shoot down the m e s s e n g e r b a l l o o n s , 2a b u t it is unclear whether it came into service in time to be effective. Five balloons were captured, although the crews of two others, which landed in occupied territory, managed to escape. T h e s t a t e m e n t t h a t hot-air balloons were used 1,9,11-14,25is another consistent inaccuracy regarding the siege. In fact, original p h o t o g r a p h s clearly show the balloons were gas filled (Figure 1).22,23 It is clear that the siege of Paris and the flights of the 66 m e s s e n g e r balloons and t h e i r 166 p a s s e n g e r s and crew should no longer be quoted as t h e i n t r o d u c t i o n of air m e d i c a l transport. Possibly, it can be argued that an 1783 m a n n e d balloon flight which involved a surgeon and a milit a r y officer as c r e w 32,34,35 was the legitimate forerunner of present day air medical transport. It is certainly a m o r e logical f o r e r u n n e r t h a n t h e p i l o t i n g of h e a l t h y c i v i l i a n s b y marines d{iring the siege of Paris in 1870. While the flights from Paris undoubtedly contributed much to aviation science, m o r e r e c e n t developm e n t s have c o n t r i b u t e d directly to :. the evolution of air medical transport. T h e f i r s t p r a c t i c a l a t t e m p t to design and build an air a m b u l a n c e was m a d e in the U . S . 4'7'31 T h e first test flight of the Rhodes-Gossman air ambulance took place on January 26, 1910, w h e n it was towed aloft by a g r o u n d vehicle. 1 Unfortunately, the air a m b u l a n c e c r a s h e d later on its

first p o w e r e d flight and no patients were ever carried. T h e credit for the first successful air m e d i c a l t r a n s p o r t a t t e m p t still goes to the F r e n c h b e c a u s e of the e v e n t s of N o v e m b e r 16, 1915, d e s c r i b e d above. T h e F r e n c h w e n t on to convert military aircraft to carry patients in litters in 1916. T h e following year they built an air ambulance c a p a b l e of c a r r y i n g two l i t t e r patients. 1,4,36 This air ambulance was u s e d s u b s e q u e n t l y for e v a c u a t i n g casualties from the Aisne front. 1,6,7 A JN-4 airplane was the first U.S. aircraft converted for air ambulance work. D r i v e r and O c k e r o b t a i n e d authorization for the c o n v e r s i o n in F e b r u a r y 1918 at G e r s t n e r Field, La. 4,7,8 Prior to that time, ordinary flying machines had b e e n used in the U.S. to carry doctors to the scene of air accidents. 7 T h e r e is e v i d e n c e 4,37 to s u p p o r t the logical assumption that it was the pilots in the early days of flight who saw the potential for aircraft to locate casualties at the scene of air crashes and on the battlefield, and who began to land to provide medical care and evacuation when other conventional means of transport were impractical. It is time for the true pioneers of air m e d i c a l t r a n s p o r t to b e r e c o g nized and for the literature on the subject to be corrected. T h e actual events of 1870 suggest that there is r e a s o n to b e w a r e of t r a n s l a t i o n errors when quoting from foreign language literature, and confirm that it is always preferable to have sight of the original paper rather than to "cite unseen." •

References 1. Lam DM: From balloon to black hawk. Part I: The origins. U.S. Army Aviation Digest 1981; 6:41. 2. Shirley RE: Air evacuation prior to World War II. In: Civilian and Military Problems in Air Medical Evacuation. USAF Aviation Medicine Symposium, Wright-Patterson Air Force Base, Ohio, 1956, p 42. 3. Chou MM, MacDonald MG: Landmarks in the Development of Patient Transport Systems in Emergency Transport of the Perinatal Patient. Boston/Toronto, Little, Brown and Company, 1989, p 2. 4. Guilford FR, Soboroff BJ: Air evacuation: An historical review. Aviat Med 1947; 12:601.

The Journal of Air Medical Transport ° August 1992

5. Munro D: The use of the aeroplane in the medical services in "~ar. President's address: Proc R Soc Med 1923; 17(3):7. 6. Darby TE: Airplane ambulance evacuation. Milit Surg 1932; 71:162. 7. Weed FW: The airplane ambulance. In: The Medical Department of the United States in the World War. Weed FW (ed). Washington,

D.C., U.S. GovernmentPrinting Office, 1923,p 416. 8. Grant DNW: Airplane ambulance evacuation. Milit Surg 1941;88:238. 9. Dobrin RS, Block B, GilmanJI, et ah The development of a pediatric emergency transport system. Pediatr Clin North A m 1982; 27 (3):633. 10. Parsons CJ, Bobechko WP: Air medical transport: Its hidden problems. Can Med Assoc J 1982; 126:237. 11. Mayer TA: Transportation of the injured child. In: Emergency Management of Pediatric T r a u m a . Mayer TA (ed). Philadelphia, Saunders, 1985,p 508. 12. Wingert WA: Setting standards for critical care transport: Fitz-Gibbon'sLaw Revisited. In: Critical Care Transport. Int Anaesthesiol Clin. Hackel A (ed). Boston, Little, Brown and Company, 1987,p 139. 13. Britten AG, Rogers MC: Transportation of critically ill children. In: Critical Care Medicine. Rogers MC (ed). Philadelphia, Williams & Wilkins, 1987,p 1,385. 14. Saunders CE: Air medical transport. In: Management of Wilderness and Environmental

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Emergencies. Auerbach PS, Geehr EC (eds). 2nd ed, St. Louis, Mosby, 1989, p 359. 15. Funsch HF, Nareff MJ, Watkins PB: Wings for wounded warriors. JAMA 1967; 200(5):391. 16. Spoor DH: The p a s s e n g e r and the patient in flight. In: Fundamentals of Aerospace Medicine. Dehart RL (ed). Philadelphia, Lea & Febiger, 1985, p 595. 17. Braswell LR: Progress in air medical evacuation. In: Civilian and Military Problems in Air Medical Evacuation. USAF Aviation Medicine Symposium. Wright-Patterson Air Force Base, Ohio, 1956, p 46. 18. Jones DR: Air medical transportation of psychiatric patients: Historical review and present management. Aviat Space Environ Med 1980; 51 (7):709. 19. Gibbons HL, Fromhagen C: Air medical transportation and general aviation. Aerospace Med 1971; 42 (7) :773. 20. Funch HR: Flying hospital wards. Aerospace Historian 1967; 14:235. 21. Golby SB: Dustoff. AOPA Pilot 1987; 30:46. 22. Azeau H: Les Balloons de l'Espoir Darts le Si~ge du Paris. Robert LaFont, Paris, 1987, pp 7-301. 23. Dollfuss C, Maincent P: La merveilleuse histoire des 66 balloons du si~ge du Paris. ICARE 1971; 56:67. 24. Dollfuss C: Voici les pilotes et les passengers. ICARE 1971; 56:181. 25. Hackel Pc An organizational system for critical care transport. In: Critical Care

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Transport. Int Anaesthesiol Clin. Hackel A (ed). Boston, Little, Brown and Company, 1987, p 1. 26. Johnson A: Treatise on air medical evacuation: I: Administration and some medical considerations. Aviat Space Environ Med 1977; 48(6):546. 27. Harris BH, Orr RE, Boles ET: Air medical transportation for infants and children. J Pediatr Surg 1975; 10(5):719. 28. Hart HW: The conveyance of patients to and from the hospital, 1720-1850. Med Hist 1978; 22:397. 29. Johnson Pc Treatise on air medical evacuation: II. Some surgical considerations. Aviat Space Environ Med 1977; 48(6):550. 30. Johnson A, Cooper JT, Ellegood FE: Five-year study of emergency air medical evacuation in the United States. Aviat Space Environ Med 1976; 47 (6) :662. 31. United States Airforce: Air medical evacuation: Background information. Washington, D.C., Secretary of the airforce, USAF office of information, 1968. 32. Taylor JWR, Taylor MJH, Mondey D (eds): The Guinness Book of Air Facts and Feats, 3rd ed, Guinness Superlatives Ltd, Enfield, Great Britain, 1977, pp 15,18. 33. Yelnick C, Joliette M: La m6t6orologie en 1870. ICARE 1971; 56:194. 34. DeHart RL: The historical perspective. In: Fundamentals of Aerospace Medicine. DeHart RL (ed). Philadelphia, Lea & Febiger, 1985, p 5. 35. Zinnemann G: Aerospace medicine past, present and future. In: Aerospace Medicine.

Randel HW (ed). Baltimore, Williams & Wilkins, 1971, p 1. 36. Anon: Carrying the seriously wounded to hospital via the air route. Sci Am 1917; 117:385. 37. Strong S: Air ambulance. Milit Surg 1919; 44:361.

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The Journal of Air Medical Transport • August 1992