Emergency Care by Air

Feb. 1, 2013

The US military has fought two long, difficult ground wars since 2001, wars where troops were injured far away from bases, in remote and hostile territory. In many cases, surviving has depended on injured personnel quickly being transported to a secure medical facility.

Over the past decade, troops surviving their combat wounds have increased significantly in number, and they can thank, in part, the Air Force’s en route care system.

An Air Force Pave Hawk assigned to the 66th Expeditionary Rescue Squadron picks up a patient in Afghanistan. Casualty evacuation by air within the theater takes place almost entirely by helicopter. (USAF photo by SSgt. Manuel J. Martinez)

“Major advancements in processes, training, technology, tactics, techniques, and procedures” have occurred over the past 10 years of war, said Brig. Gen. Bart O. Iddins, command surgeon at Air Mobility Command, Scott AFB, Ill. As AMC’s senior medical officer, he has responsibility for establishing, coordinating, and sustaining USAF’s aerial en route health care system. According to Iddins, the effectiveness and efficiency of that system, along with the development of a theaterwide trauma system, has transformed the management of combat casualties.

In 2009, then-Defense Secretary Robert M. Gates traveled to Afghanistan, promising troops more forward deployed medical capabilities. He told a group of marines his goal was “to provide the ‘golden hour’ here in Afghanistan that we have in Iraq,” referring to a standard of getting troops to advanced-level treatment facilities within 60 minutes of their being wounded.

During the Vietnam War, it typically took about a month for wounded troops to reach care facilities in the United States. Today, the Pentagon’s medical system has moved assets closer to the front lines to be more responsive to patient needs, and surgical teams are positioned closer to the troops. In addition, an extensive aeromedical evacuation capability quickly moves wounded warriors to progressively more advanced levels of care.

The emphasis in Afghanistan has clearly been on accessing medical care sooner rather than later. The battalion aid station provides first-level medical intervention. From there, patients move quickly to forward surgical teams that stabilize them, and when required, provide life- and limb-saving surgeries. Within hours, patients arrive at theater hospitals in Bagram or Kandahar via aeromedical evacuation, to receive highly specialized care.

After being evacuated from the battlefield and receiving advanced care at Landstuhl Regional Medical Center in Germany, the injured arrive at Walter Reed National Military Medical Center at Bethesda, Md., or San Antonio Military Medical Center in Texas in as little as three days.

Moving patients through this continuum of care wouldn’t be possible without a robust en route medical care system.

Col. Mark Ervin, a general surgeon and the medical director for AMC’s critical care air transport (CCAT) team, says USAF’s current formula shows a 91.2 percent patient survival rate within the entire en route medical care system.

Airmen and soldiers from a contingency aeromedical staging facility carry a patient into a C-17 at Ramstein AB, Germany. From there, he will be flown to JB Andrews, Md. (USAF photo by A1C Erin M. Peterson)

There have been a “tremendous number of individual changes to [USAF’s] CASEVAC [casualty evacuation] system,” said Ervin. He said the most far-reaching improvements come from en route care that is seamless with what patients receive at their base-hospital destinations. “When this war started, we thought of those [elements] as distinct,” he explained. “But since then we’ve worked to create a joint stream of care” without interruption.

Further, Ervin said, CCAT allows for the movement of very critical patients. “The system allows you to take care of much sicker patients than ever before,” he said. “We have continued to expand what we can do within the en route care system. At the start of the [Iraq] war, we were able to move stabilized patients—still significantly ill but fairly stable.”

Col. Robin Schultze, chief of the En Route Medical Care Division at AMC and an emergency nurse veteran of many CCAT missions, says USAF medical professionals have not let the combat environment constrain them. “They are continuing care as if they are still in a hospital at all times,” she said. “That is a tremendous change since 9/11.”

For example, USAF medical personnel have developed the concept of the “lung team” to move critically injured casualties who are on continuous heart-lung bypass. Some would previously have been too ill to move, she explained.

“Some of these patients would have died in theater, but medical professionals refused to accept that,” she said. Moving patients on heart-lung bypass by air is a complex procedure, but Schultze said the capability to save them was born of the “refusal to accept that any patient is unsalvageable.”

Because of emergency medicine physicians and critical care nurses who work aboard aircraft, “now the emergency room door is the helicopter door,” she said.

“We are now saving casualties that in any prior war never would have been saved,” said Ervin. “We are saving casualties that would never have made it to the first station.” He attributes this success rate both to the innovations in the process of stabilizing casualties en route and to advances in medical technology and knowledge. For example, hemostatic dressings are chemically treated to stop bleeding. In addition, soldiers are equipped with tourniquets that can easily be self-applied.

Many Routes to Safety

SSgt. Jason Leonard, a Reserve aeromedical technician, helps lift a patient during Iraqi Freedom in 2008 at Balad AB, Iraq. (USAF photo by SrA. Julianne Showalter)

The US military’s en route care system includes multiservice casualty evacuation and medical evacuation (MEDEVAC) typically run by the Army; tactical critical care evacuation teams, critical care air transport, and aeromedical evacuation usually run by the Air Force; and various related expeditionary patient staging systems handled by thousands of highly trained military medical personnel.

CASEVAC and MEDEVAC differ primarily because the latter uses a standardized and dedicated vehicle for providing en route care. Conversely, CASEVAC uses nonstandardized and nondedicated vehicles. The casualty evacuation system was designed to transport troops in need of evacuation from the battlefield but who do not have time to wait for a MEDEVAC, or for cases where a MEDEVAC team cannot get to the casualty.

The Geneva Conventions mandate MEDEVAC vehicles to be unarmed and marked with a red cross—the oft seen Army Black Hawks with a red cross in Afghanistan, for example. Firing on MEDEVAC vehicles is considered a war crime.

CASEVAC transports can be armed since they are used for other purposes. CASEVAC by air today takes place almost exclusively by helicopter, a practice begun on a small scale toward the end of World War II.

Aeromedical evacuation uses fixed wing aircraft to transport patients between medical treatment facilities, typically over long distances.

Training is a big piece of the improving survival rates. All of USAF’s tactical critical care evacuation team personnel—emergency medicine physicians, nurse anesthetists, and intensive care nurses—start in a CCAT training program. The CCAT course teaches these already experienced medical professionals to use their skills in a less friendly and more austere environment.

This training is followed by two weeks of advanced training at a center for trauma skills. Then comes the Joint En Route Care Course for rotary wing aircraft.

Survival, evasion, resistance, and escape training follows.

Finally, the nurses and physicians complete combat skills training with the Army to familiarize themselves with self-defense skills.

It Works

Marine Cpl. Michael Meyer during his long trip from Okinawa to Hawaii to Iowa. (Sill photo from a video by University of Iowa Hospitals & Clinics)

Examples of Air Force medical successes in the field abound. The March 2012 aeromedical evacuation of Marine Corps Cpl. Michael Meyer, who suffered complications from a lung infection and a collapsed lung, marked the first ever transfer of an extracorporeal membrane oxygenation (ECMO) adult patient by the US military in the Western Pacific region. ECMO provides cardiac and respiratory oxygen support for patients with a damaged heart and lungs.

For ECMO a surgeon inserts tubes into the patient’s large blood vessels. Blood thinners prevent clotting. A machine then pumps blood to a membrane oxygenator, removing carbon dioxide and adding oxygen.

Meyer received care at the US Naval Hospital Okinawa at Camp Lester for several days before transfer to Kadena Air Base, to fly on a C-17 for specialized care in Hawaii.

The medical team transporting him comprised not only a USAF critical care air transport team, but also the Tripler Army Medical Center joint medical attendant transport team and civilians from a Honolulu hospital. A week later the 11-person transport team moved Meyer, via the aeromedical evacuation system on a C-17, to the University of Iowa hospital system in Iowa City, Iowa.

Meyer’s lungs began to improve and, after 38 days of support, he was taken off the ECMO. By two months after his initial evacuation from theater, the marine could walk and eat and only required a tracheostomy mask collar for oxygen support.

After spending a total of 99 days in hospitals, Meyer was discharged.

Medical personnel from allied countries also take part in casualty evacuation, according to Ervin, and US medical personnel often treat partners’ military and civilian personnel.

The United States Air Force School of Aerospace Medicine at Wright-Patterson AFB, Ohio, has graduated numerous international medical personnel in a variety of courses. For example, the Advanced Aerospace Medicine Course for International Medical Officers graduated two students from Bangladesh, four from India, four from Japan, one from Singapore, two from South Korea, two from Sri Lanka, and one from Taiwan in 2011. The Aerospace Medicine Primary Course graduated two students from Australia, seven from Malaysia, one from New Zealand, and one from the Philippines. The Critical Care Air Transport Course graduated five students from Australia, four from Japan, and two from South Korea, and the Flight Nurse Course graduated four students from Australia, one from the Philippines, three from South Korea, and one from Taiwan.

Last May, the US signed a framework agreement on aeromedical evacuation cooperation with three of its allies: Australia, Canada, and the United Kingdom. This proclamation of understanding will promote and support mutual cooperation and interoperability of the aeromedical aviation assets of the four air forces, the document states.

At Camp Bastion, Afghanistan, airmen and soldiers assigned to the 76th Expeditionary Rescue Squadron move a litter from an ambulance and prepare to transfer the patient into an HC-130 for medical evacuation. (Photo by SrA. Tyler Placie)

The four signatories promised to work toward providing compatible training, equipment, and procedures so teams can work together on the same aircraft. This so-called “Interfly” agreement solidifies initial proposals made by the four nations during a summit at Scott AFB, Ill., in November 2009. Flight clearances for aeromedical evacuation equipment from the respective nations are now facilitated by Interfly, but the Air and Space Interoperability Council national directors have asked a working group to develop systems to permit mutual recognition of engineering flight clearances with the “intent of enabling Interfly missions across the full range of transport aircraft” used by the respective teams.

Allied nations all benefit from this kind of international cooperation. Early in 2012, an Air Force certified registered nurse anesthetist was called on to move a 22-year-old Afghan National Army soldier. The soldier had suffered second- and third-degree burns to more than 35 percent of his body surface area in an improvised explosive device blast. He needed to be moved from Farah province to the Zafar ANA hospital in the city of Herat.

The patient received initial airway management and resuscitative surgery from a US Army forward surgical team at Farah, and then the “stabilizing” patient was put on a US Army helicopter while under the care of the Air Force nurse anesthetist and a US Army medic. This sort of cooperation is expected to continue.

As combat operations wind down in Afghanistan, the en route care mission “will be sized up or down to meet the requirement,” said Iddins. “Even in the face of constrained budgets, we will always place the appropriate medical resources in the field and will always maintain an en route care capability” that is up to the task, he said.

Marina Malenic is the US aviation reporter for Jane’s. Her most recent article for Air Force Magazine was “Flying High,” in the February 2012 issue.