The Letterman Plan
The Letterman Plan is a system for treating and evacuating casualties from the battlefield, developed during the American Civil War. The plan was created by Dr. Jonathan Letterman while serving as Medical Director of the Union Army of the Potomac from July 1862 to the end of 1863. He presided over U.S. medical operations at some of the most famous battles of the war, including Antietam and Gettysburg.
When Letterman assumed command he found his department in great neglect and disorder. During his tenure, he not only strengthened medical operations, but entirely reconceived the task of caring for wounded soldiers. He created a comprehensive plan to handle mass casualties and synchronized all elements of medicine on the battlefield. The Letterman Plan is derived not from a single document, but from a series of reforms and programs instituted during his year and a half as Medical Director. Jonathan Letterman is remembered as the father of modern battlefield and emergency medicine. The Letterman Plan remains the foundation for elements of military medicine, as well as civilian emergency medicine and disaster relief.
An Outline of the Letterman Plan:
Creation of an Organized Ambulance Corps
- Apportions ambulances evenly throughout the army, assigning them to individual units
- Gives full control of army ambulance to officers of the ambulance corps
- Makes ambulance officers directly answerable to Medical Directors of the corps and army
- Staffs ambulances with trained and dedicated enlisted men to act as drivers and stretcher-bearers
- Forbids the use of ambulances to carry personal baggage or other non-medical uses
- Forbids the removal and transportation of wounded and sick by anyone not belonging to the ambulance corps
Prior to the Letterman Plan, little attention was paid to ambulances in armies. They were staffed with unreliable civilians or enlisted men on temporary detail. Ambulances were controlled by the Quartermaster Department, which was also responsible for the procurement, transportation and distribution of most other supplies and transportation for the army. Quartermasters had conflicting priorities and were often poorly informed of the Medical Department’s needs. Often individual officers requisitioned ambulances to carry personal baggage or other equipment for their commands. Without a reliable system, evacuation of wounded often fell to musicians and other unqualified personnel, or to individual soldiers, who reduced fighting effectiveness by stepping out of line to remove wounded comrades.
The creation of an organized ambulance corps helped to rectify these problems. The distribution of ambulances ensured that they would be nearby when needed. As a semi-autonomous organization, the ambulance corps could better meet its unique needs and focus on the task of removing and transporting wounded. Ambulance officers had the authority to manage their own ambulance trains and prevent their misappropriation by other officers. Staffing ambulances with well-trained and permanently assigned personnel meant that qualified and experienced people would be handling battlefield casualties. By granting the ambulance corps exclusive control over the handling of casualties, the Letterman Plan improved the efficiency of evacuation and reduced losses in combat effectiveness by eliminating the need for combat troops to leave action to assist wounded comrades.
Regulations for Organizing Surgical Field Hospitals
- Surgical field hospitals to be established for each division prior to anticipated engagements
- Sites for each division hospital to be selected by the Medical Director of each corps
- 1 surgeon to superintend each division hospital
- 1 assistant surgeon in each division hospital to manage supplies and physical needs
- 3 medical officers to conduct all surgical operations in each division hospital
- 3 medical officers to assist the operating surgeons in each division hospital
- Operating surgeons selected on the basis of skill and experience, regardless of military rank
- One of the assisting medical officers designated to perform all anesthesia
- Other medical officers detailed to assist in the division hospitals as available and necessary
- Surgeons admit and treat any soldier brought to their hospital regardless of his home unit
A system of organized operating hospitals moving with the army was made famous by the Mobile Army Surgical Hospitals (MASH units) in the Korean War, but the basic concept began much earlier in the wake of the Battle of Antietam. Prior to the fall of 1862, no system existed for implementing field hospitals and the medical response to battle. Surgeons operated independently and improvised medical care amidst the chaos and aftermath of battle. Little coordination existed among medical directors, supply officers, ambulances, and field hospitals that had been set up haphazardly across the field. Some hospitals were entirely neglected because officers were unaware of their existence and ambulances could not find them. Hospitals were understaffed and lacked procedures for operation, including triage, supply problems, and medical records. Often surgeons refused to treat wounded men not from their own regiments or brigades.
The Letterman Plan addressed these problems and more. It gave specific instructions for the management of surgical field hospitals, consolidated medical efforts in each infantry division, and ensured that each hospital was pre-determined and coordinated with other medical personnel. While hospitals were designed to care for casualties in their respective divisions, they would not turn away any wounded, even the enemy. The new organization rejected the traditional importance of military rank by requiring that operating surgeons were selected by skill and qualification. The selection of one designated officer to administer anesthesia was also unprecedented in a time before medical professionals specialized in the field of anesthesiology.
Advent of Forward First Aid
- At least one surgeon or assistant surgeon detailed to each regiment
- In battle, regimental surgeons establish temporary medical stations in the rear of action
- Medical personnel provide immediate care to wounded soldiers
- These stations serve as focal points of evacuation by ambulance
These locations, which Jonathan Letterman termed “temporary depots” are the beginning of modern aid stations on the battlefield. While it took time to bring casualties to established field hospitals, forward medical officers could provide immediate care to stop bleeding and stabilize wounded soldiers. The organization of these forward stations helped to shelter wounded from immediate danger and provided a central location for ambulances to find and remove wounded to hospitals. At the Battle of Antietam only two aid stations are documented on the battlefield, but by the Battle of Gettysburg less than a year later, the majority of casualties were processed through aid stations before being removed to more substantial field hospitals.
Introduction of Triage
- Wounded are treated and evacuated in order of priority
- Use of a 3 – tier system of priority
- Most serious but survivable wounds are first priority
- Less serious wounds are second priority
- Likely fatal wounds (head, abdomen, etc.) are last priority
- “Dressers” in field hospitals prioritize and prepare wounded for surgery
Early battlefield medicine operated on a system of first come, first served. This was replaced during the Civil War by the universal application of triage as part of the Letterman Plan. American surgeons did not invent triage – it was already being used sporadically by surgeons in Europe and Russia – but the Union Army was the first to apply it formally and uniformly in the field. This began in field hospitals where medical officers were assigned to act as “dressers,” preparing patients for surgery and organizing them in order of urgency. Cases considered hopeless were made comfortable and treated last. As the war progressed, this system of prioritizing the wounded was extended to forward “aid stations” and the order of evacuation from the battlefield.
Long-Term Recovery Hospitals on the Battlefield
- Patients too severe to be transported to hospital centers are cared for near the battlefield
- Large tent hospitals are constructed to house patients for up to several months
Severely wounded soldiers had always been left on or near the battlefield, too unstable to move with the army or to long-term hospitals. Traditionally, these men were left the care of local civilians, or worse yet, with no provisions for their care. The Battle of Antietam was the first time that the Army established recovery hospitals at the battlefield to provide organized long-term care to wounded soldiers by military surgeons. This improved the quality of care for patients and reduced the burden placed on the local community. Care of many wounded still fell to private residences, but was supervised by military medical officers.
Staged Evacuation and Treatment System
- Frontline medical officers gather and stabilize casualties, creating temporary stations
- Ambulances carry wounded from the battlefield
- Field hospitals treat wounded and deliver surgical operations
- Wounded are moved from field hospitals to long-term care
- In many cases, wounded are moved by rail on special hospital cars or by water aboard hospital steamers to large general hospitals in major cities.
Prior to the Letterman Plan, no comprehensive system existed for the care of wounded in major battles. Different elements of the medical system operated independently, some under the authority of non-medical officers. The Letterman Plan unified all medical activities into a comprehensive system, joining separate commands into a cohesive organization with the singular objective of saving lives. It established a continuous chain of care to take casualties from the moment of injury to recovery in long-term hospitals. Explicit instructions for the transfer of wounded from one level of care to the next helped to alleviate the chaos caused by uncertainty, ill-defined responsibilities, and poor communication. Modern military and civilian emergency medicine mirror this staged evacuation and treatment system, though often on a larger scale.