The Mobile Army Surgical Hospital (MASH):

A Military and Surgical Legacy

Maj. Booker King, MD, FACS, and Col. Ismail Jatoi, MD, PhD FACS
Heidelberg, Germany and Bethesda, Maryland

The opinions and assertions contained in this article repre- INTRODUCTION

sent the private views of the authors and should not be con- Mobile Army surgical hospitals (MASH) were
strued as reflecting the official views of the Department of designed to keep pace with combat units during time of
the Army or the Department of Defense. war, providing immediate, lifesaving care to casualties.
MASH units have been deployed in every major U.S.
Operation Iraqi Freedom was perhaps the last military cam- military conflict since World War II and are undoubted-
paign that will ever utilize the services of a mobile Army sur- ly responsible for saving thousands of lives on the bat-
gical hospital (MASH). The Army has now essentially tlefield. Interwoven with this history of the MASH is
replaced the MASH with combat surgical hospitals (CSH) the history of resuscitation and care of combat casual-
and forward surgical teams (FST). MASH units were designed ties. The authors of this article recently served with the
as mobile, flexible, forward-deployed military hospitals, pro- 212th MASH during Operation Iraqi Freedom. The
viding care for the wounded near the frontlines of the bat- 212th entered Iraq on the first day of the war and cared
tlefield. These hospitals not only saved thousands of lives dur- for a large number ofboth military and civilian casual-
ing war but also greatly influenced the delivery of trauma ties during the initial weeks of this military campaign.
and critical care in civilian hospitals. The MASH was made In this article, we chronicle the history of the MASH
popular by the television series of the 1970s, depicting the and outline its many contributions to military and civil-
4077th during the Korean War. Although a comical series, ian trauma care.
these television episodes provided viewers with a glimpse of
life in a MASH during time of war. This article chronicles the World War II: Birth of a Concept
history of the MASH from its inception during World War 11 to Many concepts implored in modem military sur-
recent expenences in Operation Iraqi Freedom. gery can be traced to the innovations of Baron Dom-
inque Jean Larrey during the Napoleonic Wars.' Lar-
Key words: mobile Army surgical hospital a forward rey, hailed by many as the father of combat
surgical teams * combat support hospitals C mobile medicine, laid the foundation for medical evacuation
hospitals U military medicine U Army medicine * field as we know it today with his "ambulance volante."
hospitals U war surgery He was also one of the first military physicians to
conceptualize forward surgical hospitals by bringing
medical support to the frontline. These concepts
translated later to the mobile units of World War II
and the Korean War.
During the later part of World War II, it became
apparent that the transport of patients to field hospitals
and general hospitals in the rear was time-consuming
and cost many lives.2 The notion of providing immedi-
ate lifesaving treatment to soldiers on the battlefield
© 2005. From the Department of Surgery, U.S. Army Hospital Heidelberg was therefore introduced. This meant that special surgi-
(King, Major, U.S. Army Medical Corps), Heidelberg, Germany and the cal teams needed to be deployed closer to the front-
Department of Surgery, Uniformed Services University of the Health Sciences, lines. The field hospital was the Army's most mobile
Bethesda, MD (Jatoi, Colonel, U.S. Army Medical Corps), Send correspon-
dence and reprint requests for J NatI Med Assoc. 2005;97:648-656 to: medical unit at the beginning ofWorld War II.3 These
Booker King, Department of Surgery, U.S. Army Hospital Heidelberg, hospitals were comprised ofthree or four smaller units,
APO AE 09042; phone: 01 1-49-6221-172631; fax: 001-49-6221-173343; e-mail: with a combined 400-bed capacity. These medical units
[email protected] were generally situated near airfields, to facilitate

648 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 5, MAY 2005
 THE MOBILE ARMY SURGICAL HOSPITAL

transport of injured patients out of the combat zone. to soldiers on the battlefield (Figure 1).4'5 The surgical
Field hospitals were large, fixed facilities, unable to consultants division recommended the creation of
advance with rapidly moving combat troops, and evac- "auxiliary surgery groups" (ASGs). These were to be
uation to these hospitals required the use of ground small, mobile units attached to larger field and evacua-
ambulance. The time required for evacuation was often tion hospitals. Brigadier General Fred W Rankin (head
lengthy, and many of the most severely injured patients of the surgical consultants division) and General Nor-
did not survive transport. man T. Kirk (surgeon general of the Army) immediate-
In the early 1940s, Colonel Michael DeBakey (one ly endorsed these recommendations. Initially, there was
of the founders of modem cardiac surgery) and other difficulty in convincing some members of the Army
members of the surgical consultants division were giv- staff to adopt this concept. However, the eventual effec-
en the task of providing the surgeon general with rec- tiveness ofthese mobile units in combat soon alleviated
ommendations on the optimal delivery of surgical care any skepticism.
ASGs were effective despite the relative inexperi-
ence of their surgeons. Many of these surgeons had
Figure 1. Colonel (Dr.) Michael DeBakey receiving less than three years of surgical training. However,
the Legion of Merit Award from General Rankin for these groups were successful in providing resuscita-
his contributions to the development of the MASH
(photograph courtesy Dr. Michael DeBakey). tion, surgical management and postoperative care in

Figure 2. Surgery performed at 1st MASH in Korea

(from AMEDD history website with permission).28

...
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.__ I I.

........... ..I

*~~~~~~~
~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ...e.

......................................................
.-II.. ........... ...............

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)
Baffle Deaths Wounded in Action Died of Wounds Postevacuation Mortality
(Army) (Army) (Army) (All services)
World War 50,510 (1.2%) 193,663 (4.8%) NA 8.5%
World War 11 234,874 (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
NA: Not Available; * Data from March 19, 2003 - September 25, 2004; + Slight increase in mortality thought to be attributable to
increased evacuation of critically injured patients; Data prepared from: Washington Headquarters Services, Directorate for
Information, Operation and Reports

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 5, MAY 2005 649
THE MOBILE ARMY SURGICAL HOSPITAL

the battle zone.24 Each ASG consisted of a chief sur- renamed "Mobile Auxiliary Surgical Hospitals" and
geon, an assistant surgeon, an anesthesiologist, a later "Mobile Army Surgical Hospitals."
surgical nurse and two enlisted technicians. Special-
ized teams were also formed, with surgeons selected The Korean War: The War that
from various disciplines, including thoracic surgery, Defined the MASH
neurosurgery, plastic surgery, maxillofacial surgery On Sunday, June 25, 1950 the North Korean Peo-
and orthopedics. Four such ASGs were initially ple's Army crossed the 38th parallel into South
organized during World War II, and a fifth group Korea. This led to the Korean War, which lasted
was added later. nearly three years.6 One of the defining aspects of
The Second Auxiliary Surgical Group, under the the Korean War was the use of the MASH. Ten
command of Colonel James C. Forsee, was the first MASH units supported four Army divisions (15,000
mobile surgical hospital activated during World War to 20,000 soldiers per division) at positions through-
II. This unit supported the Fifth Army (160,000 out North and South Korea. During the Korean War,
troops) in North Africa, Sicily and Italy in 1943. The the experiences of these MASH units translated to
ASGs were able to maneuver with combat units and improvements in resuscitation and trauma care,
sustained operations within a few miles of the front- patient transport, blood storage and distribution,
lines. This led to shorter evacuation times, earlier patient triage, and evacuation.7
resuscitation of the wounded and reduction in casu- At the beginning of the Korean War, very few
alty deaths. At the time of the Allied invasion of U.S. military medical units had any experience in
Normandy, ASGs were called to support the First, northeast Asia. Colonel Chauncey Dovell, Eighth
Third, Seventh and Ninth Armies. Shortly before the U.S. Army surgeon, quickly dispatched MASH units
beginning of the Korean War, the ASGs were to Korea to provide medical support.8 MASH units
were able to rapidly deploy and quickly adapted to
Figure 3. Receiving ward at MASH in Korea (from the rugged Korean terrain. The 8063rd MASH, sup-
AMEDD history website with permission).28 porting the famed 1 st 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.
Major advances in patient transport and evacua-
tion 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.9 During the Korean
War, helicopters, referred to as "air ambulances"
were introduced, and these aircraft evacuated
Figure 4. Operating room of the 44th MASH in wounded soldiers from battlefield positions to
Korea in 1954 (from AMEDD history website with MASH units near the frontline. In 1951, the 8063rd
permission).28 MASH was the first unit to use helicopters to evacu-
ate casualties. The Bell H- 13 was the primary heli-
copter used for "Medevac" (medical evacuation).
Two patients were transported on skids placed out-
side 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

650 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 5, MAY 2005
 THE MOBILE ARMY SURGICAL HOSPITAL

(World War I, 8.5%; World War II, 4%; and Korean inferior to blood in perioperative resuscitation. The
War, 2.5%) (Table 1). importance of artificially warming the injured
Although the concept of field triage was not initi- patient was also rediscovered (a practice first
ated during the Korean War, it certainly underwent described by Walter Cannon in World War I). At the
substantial modifications during this conflict.'0 start of the Korean War, blood and other fluids were
Triage was initiated at battalion aide stations (each infused through glass bottles without filters, and
supporting up to 1,000 soldiers per battalion), which some cases of air embolism were reported. As a
were small medical units with limited capabilities. result of these reports, filters were added to the infu-
At these stations, nurses and general medical offi- sion bottles.
cers were responsible for deciding whether to evacu- The importance of adequate debridement of devi-
ate wounded soldiers or return them to duty (after talized tissue also became evident during the Korean
minor therapy). Soldiers that were evacuated to War.7 A significant number of soldiers presented with
MASH units were triaged further, depending on the open wounds of the extremities and trunk. As a result
extent of their injuries and hemodynamic status. of the experiences during World War II, definitive
Many deaths occurred at battalion aide stations. care of open wounds was never done at the MASH
Consequently, more experienced personnel were during the Korean War. Following initial debridement
assigned to battalion aide stations and equipped to and irrigation of open wounds at the MASH, local
perform simple lifesaving interventions, such as wound care continued until definitive surgery was
placement of tourniquets and insertion of chest tubes.
Patients needing surgery and all critical patients were Figure 5. Aerial view of the 212th MASH in Iraq
rapidly evacuated to the MASH by helicopter. At the (80 miles south of Baghdad).
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 prece-
dence over limb, function over anatomical defects."
There were numerous improvements in periopera-
tive care and anesthesia during the Korean conflict,
based on experiences at the various MASH units.'"'3
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 Figure 6. 212th MASH personnel resuscitating a
some patients; however, acute renal failure was seen casualty in the triage area.
in 0.5% of casualties evacuated from the battlefield.
Acute renal failure in this setting yielded high mortal- "' S ' ;4t'~~~~~~~~I..: i

ity despite supportive care (80-90%). Anesthesiolo-

gists adopted the practice of using small amounts of
narcotic for induction. Chloroform and ether were a -.

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.
MASH surgeons performed numerous retrospec-
tive studies that soon greatly influenced trauma care
around the world.'4"5 Experience from the Korean
War showed that intravenous vasoconstrictors were

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 5, MAY 2005 651
THE MOBILE ARMY SURGICAL HOSPITAL

eventually performed at hospitals in the rear. Peni- United States. Blood was delivered to Korea by air.
cillin was administered and continued postoperatively Shipments were then taken to medical supply
for several days. The use of tetanus toxoid was initiat- depots, where blood was stored and distributed to
ed and routinely administered to all patients with pen- hospitals in the combat zone. At the MASH, most of
etrating injuries. Surgeons came to realize that antibi- the blood was transfused just prior to evacuation of
otics could not adequately treat wounds unless the injured. Battalion aide stations and other lower-
thorough debridement had been performed. level medical units had little blood in supply. Due to
Several advances in vascular surgery occurred the large influx of patients and limited ability to
during the Korean War. Paramount among these was resuscitate casualties, the medical units below the
improvement in surgical techniques of vascular level ofthe MASH rarely transfused patients.
injury repair.'6"17 Ligation of injured vessels was stan- The 4077th MASH television series that was
dard in World War II, with few repairs attempted. Vas- widely viewed during the 1970s was based on
cular repair during the Korean War, however, led to a Richard Hooker's experience as a surgeon during the
significantly lower amputation rate when compared Korean War. The living conditions shown in this
with World War 11 (13% vs. 36%). Autologous vein series seemed harsh. However, the conditions in the
and arterial homografts were commonly used for actual MASH were far worse.7'9 MASH personnel
arterial reconstruction. Improvements in medical had to endure extremes of temperature and rugged
evacuation allowed for arterial injuries to be treated mountainous terrain. Their convoys traveled through
an average of 9-14 hours after wounding, thereby treacherous battlegrounds, and the hospitals were
leading to better rates of limb salvage. assembled only a few miles from the frontline.
The logistical difficulties in the storage and allo- MASH units often moved several times each month
cation of blood led to the development of a blood to keep pace with combat units. Medical personnel
program during the Korean War.'8 In the early days worked long hours to care for the large influx of
of the war, blood was collected and delivered by the casualties, and surgeons operated continuously with
406th Medical General Laboratory in Tokyo. The little relief. In some MASH units, monthly admis-
mission of the 406th Medical General Laboratory sion rates of over 3,000 casualties were not un-
was to control the distribution of type-specific blood common. Compounding all these hardships was the
to hospitals in Japan and mobile hospitals through- vulnerability of the MASH units to enemy attacks
out the theater of operations. Concomitantly, type-O and short-range artillery.
blood was shipped directly from the continental The MASH personnel endured rigorous living con-
ditions and large casualty

~~~~~
IFigure 7. Surgeons operating in the portable operating container of the
212th MASH in Iraq.

-s

* _
N#,
==- ,....,..

w..+.
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
w
that the war was ending,
and six MASH units were
left in Korea (five ofwhich
were active). These remain-
ing units were given the
responsibility to treat pris-
V> r oners of war and civilian
casualties.
ky~~*a,
{Z i tT --
Vietnam War:
MUST vs. MASH
The Vietnam War was
radically different from
either the Korean War or
World War II. Guerilla tac-
tics employed by the Viet-
cong required drastic
changes in combat philoso-
phy, with resulting changes

652 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 5, MAY 2005
 THE MOBILE ARMY SURGICAL HOSPITAL

in combat medical support.20 During this conflict, the in cases of blunt trauma or blast injuries, where
"battlefront" was not readily evident. Therefore, some internal abdominal injuries were less obvious.
military planners did not regard mobile hospitals as There were novel improvements in the care of
essential. Thus, some U.S. military hospitals in Viet- the burned patient.26 Military surgeons developed
nam were established as semi-permanent, fully sulfamyalon and came to realize that fluid resuscita-
equipped facilities. tion was vitally important in the treatment of bums.
The Medical Unit Self-Contained Transportable This resulted in a 50% reduction in mortality for
(MUST) units were introduced in Vietnam.2' These burn patients in the Vietnam War, compared to the
were expandable, mobile shelters with inflatable ward Korean War. The importance of aggressive debride-
sections. Expandable sections were also provided for ment of phosphorous burns was also emphasized,
the radiology, laboratory, pharmacy, dental and kitchen improving survival of patients exposed to this agent.
areas. Most notable among the MUST units was the Equally important were improvements in anes-
45th Surgical Hospital in Tay Ninh, Vietnam. In thesia and critical care. Surgeons in the Vietnam
November 1966, following construction of a semiper- conflict began to realize the importance of perioper-
manent facility, mortars struck the hospital. The hospi- ative fluid resuscitation.27-30 Blood, plasma, low
tal commander, Major Gary P. Wratten, was killed. The molecular weight dextran and crystalloid were all
hospital then set up a new position in northeast Tay used for resuscitation. The benefit of resuscitation
Ninh. It was subsequently again struck by mortar, with- with balanced salt solutions as well as whole blood
out sustaining serious casualties. The 45th Surgical was demonstrated by studies conducted at the Naval
Hospital performed exceptionally well despite these Support Activity in Da Nang. These studies clearly
incidents, and the MUST equipment was provided to showed that balanced salt solutions replete the extra-
several more surgical hospitals that deployed to Viet- cellular compartment and are therefore an essential
nam. MUST units remained semipermanent, relatively component to the resuscitation of patients in hemor-
stationary facilities during the early years of the war. rhagic shock. Plastic bags replaced glass bottles and
However, in 1968, the U.S. Pacific command surgeon became a more efficient means of transporting
ordered that all MUST units become mobile. Thus, the blood and crystalloid. Central venous catheters were
MUST units then assumed the role traditionally rele- placed in some casualties to guide fluid therapy.
gated to the MASH. For the remainder of the war, Central venous pressure was measured by a standard
MUST units were ordered to maintain their equipment manometer, and arterial catheters were often placed
and training to ensure mobility. to obtain serial arterial blood gases. Anesthesiolo-
One of the few MASH units deployed to Vietnam gists began using halothane, which had fewer nega-
was the 2nd MASH.22 The 2nd MASH was active in tive inotropic effects. Newer techniques in the man-
south Vietnam from October 1966 to July 1967. Dur- agement of ventilated patients led to earlier
ing this nine month period, 1,011 surgical cases were extubation in the rear hospitals.
performed at this 60-bed unit. The experience of the "Da Nang Lung" or acute respiratory distress syn-
2nd MASH has been extensively chronicled. At the drome (ARDS) was seen in casualties with severe
2nd MASH, the management ofhigh-velocity wounds, hemodynamic compromise who often required mas-
vascular trauma, colorectal injuries and burn injuries sive blood transfusions.31'32 ARDS was not seen in ear-
were vastly different from that of the Korean War era, lier conflicts, since soldiers who were severely com-
reflecting innovations in the delivery of surgical care promised often did not survive transport to even
that had occurred during the preceding decade. Addi- forwardly mobile medical units. Surgeons initially
tionally, improvements in aeromedical evacuation con- used diuretics and fluid restriction to treat ARDS with
tributed significantly to a decrease in mortality. little success. Clinical suspicion became the best
In Vietnam, surgeons in the MUST and MASH diagnostic tool as ARDS is often advanced once
units contributed to several major innovations in detected on chest radiograph. The hypoxia seen in
combat casualty management, particularly in wound these patients was refractory to standard oxygen ther-
and burn care.23 Early debridement of high-velocity apy. The work of Colonel Robert Hardaway and Dr.
missile wounds and delayed primary closure were David G. Ashbaugh showed the value of continuous
universally practiced among military surgeons in positive airway pressure in the maintenance of ade-
Vietnam. Further improvements in vascular surgery quate arterial oxygenation in patients with ARDS.
during the Vietnam War resulted in an average The guerilla warfare in Vietnam led to additional
amputation rate of 8%. Once again, this reduction in improvements in aeromedical evacuation. Air ambu-
amputations was due to improvements in surgical lances were responsible for saving thousands of lives
technique but more directly related to an average in the battlefield. The UH- 1D (Huey) transported
evacuation time of two hours.24'25 Exploratory laparo- six-to-nine patients at one time.33 Most patients were
tomies were performed more frequently, particularly evacuated within 30-35 minutes following injury,

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 5, MAY 2005 653
THE MOBILE ARMY SURGICAL HOSPITAL

with few evacuations occurring after more than two lowed lasted only 100 hours, with 148 U.S. troops
hours. Flight medics were skilled and competent at killed and 458 injured. Medical assets were mobilized
transporting severely injured casualties. "Dust-off" to support a rapidly advancing army. The larger, less
was the call sign used to summon these courageous mobile, combat support hospitals (CSHs) were
aviators. As a result of efficient and expeditious deployed along with the highly mobile MASH. The
evacuation, overall hospital morality was 2.6% dur- CSH units contained 3-4 operating tables and up to
ing the Vietnam War. Ironically, this was slightly 200 intensive care and ward beds. These units utilized
higher than that seen during the Korean War (2.5%). deployable medical systems (DEPMEDS) or tent
This paradox can best be explained by the fact that expandable modular personnel (TEMPER), which
improvements in aeromedical transport allowed were durable and easily erected in any environment.
evacuation of more very severely injured patients to The CSH units were large and relatively nonmobile,
nearby hospitals. Many of these patients would not and only portions of these units deployed to forward
have survived the longer evacuation time required areas of the battlefield. The smaller elements of the
during the Korean War. CSH were known as forward surgical elements (FSE)
During the early years of the Vietnam War, the or forward surgical teams (FST) and consisted of a
Air Force used cargo planes to evacuate patients to triage/patient receiving area, 1-2 operating tables and
hospitals in the rear. By 1968, casualty evacuation 6-8 postoperative and intensive care beds.
had increased to almost 6,000 patients per month. Similarly, the 5th MASH was broken up into small-
The Air Force then dedicated several C-18 air- er units to improve flexibility and mobility.37 Four sur-
planes for aeromedical evacuation. These aircraft gical units were created from this break-up: the FST,
were supplemented with special medical equipment FSE, MASH (-) and the main body of the MASH. The
and medical personnel. FST was designed to advance ahead of the main
One of the hallmarks of the Vietnam War was the MASH unit and capable to receive patients within two
development of an organized military blood pro- hours ofarriving at its destination. The FST had limited
gram.34 The distribution of blood was initially regu- supplies and could function independently only for
lated at the 406th Medical Laboratory in Japan. 24-36 hours. The FSE, like the FST, could be assem-
Mobile teams were created to procure and distribute bled in two hours. It consisted of 1 10 personnel and
blood to hospitals in Vietnam. However, type-specif- four operating tables. FSEs were intended to sustain
ic blood was distributed to hospitals in Japan, while operation for much longer than the FST. The MASH (-)
universal donor 0-negative blood was transported was a 36-bed hospital with 3-4 operating room tables,
directly to Vietnam. Physicians recognized and treat- intended as a more rapidly deployable version of the
ed coagulopathies resulting from massive hemor- MASH. The main body of the MASH had six operat-
rhage and disseminated intravascular coagulation. ing room tables and 60 ward and intensive-care beds
Various strategies were adopted to treat coagulopa- with separate sections for radiology, pharmacy, labora-
thy, including the administration of fresh blood, tory, central material supply and patient administration.
fresh frozen plasma, cortisone, heparin and epsilon It should be noted that the various smaller units of the
aminocaproic acid. Advancements-including the MASH treated a large number of both military and
use of adenine to preserve cells, new methods of civilian casualties throughout the war with consider-
refrigeration and styrofoam blood containers-also able success.
occurred in the storage of blood. These advance- The 5th MASH FSE was the first portion of the
ments resulted in an average increase in shelf life of MASH to deploy into Iraq, and sustained operations
whole blood and blood products from 21 -to-40 days. for 48 hours. The FSE then joined the MASH (-) and
advanced even further. Of note, the MASH (-) cared
The Gulf War for the injured for seven days inside enemy territory.
Operation Desert Storm was the first major conflict The FST was the final element to deploy and move
involving U.S. forces since Vietnam.35'36 Over 500,000 deeper into Iraq and remained operational for one
U.S. troops were deployed, with thousands of addition- week, supported by surrounding medical units.
al coalition forces. It was clear from the onset that this A large controversy arose in the Army medical
war would be fought with a radically different strategy. department after the Gulf War.38 Many questioned
The exceedingly rapid mobilization of troops and the ability for MASH units to rapidly deploy and
equipment ushered in a new era of military medical keep pace with highly mobile light infantry divi-
care. Medical units had to become smaller, more flexi- sions. Many MASH units were decommissioned to
ble and more mobile. allow the development of more mobile FSTs, which
Operation Desert Storm was initiated with a pro- would go on to play an integral role in the war
longed air campaign that lasted 38 days (January 17 to against terrorism in Afghanistan and have a promi-
February 24, 1991). However, the ground war that fol- nent role in this recent conflict in Iraq.

654 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 5, MAY 2005
 THE MOBILE ARMY SURGICAL HOSPITAL

The Balkans: Peacekeeping Missions operating room if emergency surgical intervention

The signing of the Dayton Peace Accord ended was required. Both operating tables could be utilized
years of ethnic strife in the former Yugoslavia. The simultaneously with full anesthesia support. Postop-
North Atlantic Treaty Organization (NATO) dis- erative patients were taken to the intensive care unit
patched troops for a peacekeeping mission in for further care and preparation for evacuation.
December 1995.39 Approximately 30,000 U.S. sol- Many soldiers sustained injury that precluded their
diers were deployed. Units from several nations pro- return to duty. These patients were evacuated by hel-
vided medical support. In this conflict, there were icopter or aircraft to higher echelons of care.
very few U.S. military casualties, and the deployed Shortly after the fall of Baghdad, it became
medical units primarily treated injured civilians. apparent that the needs of the Iraqi medical commu-
The 212th MASH (now the last MASH in the nity needed to be addressed urgently. Several mem-
Army) was deployed to provide medical support as part bers of the 212th MASH, in conjunction with the
of the "initial stabilization force" (IFOR). The 212th 30th Medical Brigade, were tasked to evaluate hos-
MASH operated a 30-bed facility that provided lifesav- pitals in Baghdad and assist in the delivery of donat-
ing care to soldiers injured in combat. However, much ed medical supplies. These hospital assessments
of the efforts of the MASH were directed towards pro- revealed basic infrastructural deficiencies and
viding humanitarian assistance to the local civilian requirements for potable water, fuel for hospital
population. In recent years, the 212th MASH has pro- generators and security to prevent looting. Hospitals
vided humanitarian assistance in Bosnia-Herzegovina, in the Baghdad area adapted quickly to the crisis and
Croatia, Kosovo and Macedonia. were functional within days after the fall of the city.
Operation Iraqi Freedom CONCLUSION
The 212th MASH played a prominent role in the Since World War II, MASH units have provided
recent conflict in Iraq. The 212th is a 36-bed hospi- immediate, lifesaving surgical care on the battle-
tal with six emergency room beds and two operating field. The experiences of the surgeons and anesthe-
room tables.40 The personnel assigned to the MASH siologists assigned to these units have translated, in
were trained to set up the entire hospital in 12 hours many instances, to important innovations in the
(Figures 5-7). However, this proved to be a labori- delivery of civilian trauma care. The 212th MASH is
ous undertaking, requiring considerable manpower. the last MASH in the U.S. Army due to be decom-
During Operation Iraqi Freedom, the clinical missioned in the latter part of 2006. The 212th con-
staff of the 212th MASH consisted of two general tributed greatly to the recent combat operations in
surgeons, a thoracic surgeon, plastic surgeon, ortho- Iraq and will undoubtedly become part of the lasting
pedic surgeon, gynecologist, anesthesiologist, emer- military and surgical legacy of the MASH. The les-
gency medicine physician, internist, family practi- sons learned from MASH units during the last 60
tioner and nursing staff from various disciplines. years will, no doubt, form the basis for the design of
The 212th MASH was the first U.S. military hospi- future mobile military medical units.
tal to enter Iraq during the war (on March 21, 2003)
and provided medical care to the advancing 3rd ACKNOWLEDGEMENTS
Infantry Division. Not since the Korean War was a The authors would like to acknowledge Col.
MASH unit able to demonstrate this sort of mobility. Michael DeBakey, MD; Col. John Cho, MD; Jean
There were 100 operations performed during 19 Murphy; Lewis Barger; Jennifer Petersen, RN; and
days of active combat (March 27 to April 14, 2003). Andrew Pizor for their assistance in preparing this
A high proportion of injuries treated at the MASH manuscript. The authors also acknowledge all the
involved the extremities. Wounds were generally members of the 212th MASH and 30th Medical
debrided and kept open, and eventually closed at Brigade for their dedication and courage in Opera-
hospitals in the rear. There were few head and torso tion Iraqi Freedom (March to June 2004), "Skilled
injuries among U.S. troops, attributable to the body and Resolute."
armor worn in combat.
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THE MOBILE ARMY SURGICAL HOSPITAL

About the Author

ooke ,ing attend e SphieDavs Shl of iomedic Edutio t t t Co of New
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