Aviation Week & Space Technology
Jim Mathews
Monday, 28 July 2014

U.S. armed forces quietly made medical history in March, when statisticians recorded zero combat-related fatalities among American service members deployed in Afghanistan. To be sure, the pace of operations has slowed from its peak a few years ago and that can partly account for the drop, but forces continue to engage and troops continue to be in harm’s way. In fact, during that record-setting March, seven American battle injuries were severe enough to require aeromedical evacuation. So far in 2014, 23 U.S. service members have died, and 93 suffered battle injuries that prompted an air evacuation.  Even so, the statistics for the duration of the wars show that the risk of dying in combat for U.S. military personnel wounded in Afghanistan and Iraq was almost half that faced by service members wounded in Vietnam in the 1960s and 1970s, and about 45% of that for World War II combatants. While there are many reasons for this—simple things such as soldiers’ improved self-care and buddy-care training along with widespread adoption of tourniquets play a role—perhaps the most decisive has been a shift in thinking about how to use helicopters, turboprop transports and long-range airlifters to project very sophisticated and complex medical care deeper into the battlespace than ever before, even to the point of injury.  We have spent 13 years developing the most complex and the most effective by far deployed trauma system in the history of warfare,” says Air Force Col. (Dr.) Mark Ervin, a general surgeon who oversees the medical aspects of three Air Mobility Command programs that fuse airpower with doctors, nurses, medics and technicians. The Critical Care Air Transport Team (CCATT) (see WWW.CCATT.INFO), the Tactical Critical Care Evacuation Team (Tccet) (see http://ow.ly/zt1zC) and En Route Critical Care programs send surgeons, trauma nurses, nurse-anesthetists, operating-room technicians and paramedics far forward to deliver care comparable to that received in an intensive-care unit or a Level I trauma center emergency room, either at the point of injury or in the air. It is difficult, complex and—until these conflicts—unheard of. “Part of why we’re so good today is [nearly] 14 years of practice,” says Air Force Brig. Gen. (Dr.) Kory Cornum, Air Mobility Command surgeon. Cornum, a pilot and an orthopedic surgeon by training, shares the concern of many in the military medical community that with the coming drawdown, maintaining that combined clinical and aeromedical evacuation know-how could be a challenge. 


The soldier on the military cargo plane struggles to breathe. He developed pneumonia while serving in Afghanistan and needs medicine now, but the pump to deliver it won't work properly. "I can't believe I'm still messing around with this pump," the nurse says, speaking on a headset because the three-person crew is surrounded by the constant roar of jet engines even as she struggles with the thin air at 30,000 feet. But those engines aren't real. The "plane" is a simulation center deep inside the University of Cincinnati Medical Center, the pump failure orchestrated from a control room next door. The patient is a mannequin. The whole thing, in fact, is a training exercise, with those in the control room recording every word and reaction. "There are communication issues for sure," said Air Force Maj. Daniel Cox after the training exercise is done. "(The doctor) has got to be more vocal." "The cadre," 17 Air Force trainers housed here at the University of Cincinnati, is charged with developing a new generation of war doctors, nurses and respiratory therapists. The university is one of three training sites for Air Force doctors, including those in the National Guard and Reserves, about to be deployed to Afghanistan or other active theater. The other training sites are in Baltimore and St. Louis. Once deployed, the doctors, nurses and respiratory therapists will treat injured service members being flown to other sites in theater or to an American military hospital in Germany. Most have backgrounds in critical care, but they often haven't seen the range of injuries common in America's 21st century wars: blast injuries, amputations, multi-trauma head injuries. "It can be a difficult transition," said Lt. Col. Elena Schlenker, deputy director of the training program, called C-Stars, or Center for Sustainment of Trauma and Readiness SkillsThere are all kinds of rules for pilots. How often can they fly? How far can they fly? But there are no rules for the people in the back of the aircraft. Richard Branson, University of Cincinnati surgery professor. Even for doctors and nurses active in the military, the stress, confined space and oxygen-deprived conditions in transport planes can be overwhelming, said University of Cincinnati surgery professor Richard Branson. The experiments hone in on how altitude affects not only the patients, but the caregivers and their equipment as well. "There are all kinds of rules for pilots," he said. "How often can they fly? How far can they fly? But there are no rules for the people in the back of the aircraft."


Master Sgt. Jennifer Higgs, 455th Expeditionary Aeromedical Evacuation Squadron technician, conducts an equipment function check inside a C-130 Hercules Feb. 21, 2013, on Bagram Airfield, Afghanistan. The 455th EAES performs its missions on fixed wing aircraft, including the C-17 Globemaster III, C-130 Hercules and KC-135 Stratotanker, and can provide extensive critical care capability with the Critical Care Air Transport Teams.
BAGRAM AIRFIELD, Afghanistan — More than 70 years ago, the first flight nurse graduated from the flight nurse course on Bowman Field, Ky. These flight nurses trained to provide a higher level of care to patients while they traveled by aircraft to other medical facilities.  Today, the flight nurses and technicians of the 455th Expeditionary Aeromedical Evacuation Squadron keep that level of care going in the skies above Afghanistan.  The 455th EAES provides medical and nursing care in flight to ill or injured service members or Department of Defense civilians. They perform their mission on fixed wing aircraft, including the C-17 Globemaster III, C-130 Hercules and KC-135 Stratotanker, and can provide extensive critical care capability equal to the level of care that patients receive at the Craig Joint Theater Hospital here.  “Our job is to move the sick and injured through the area of responsibility of Afghanistan,” said Col. Edward Farley, 455th EAES commander. “We obviously don’t want to be very busy, because that means that something bad has happened, and we have to move our service members or our coalition partners to a higher level of care.”  Farley, deployed from Scott Air Force Base, Ill., leads 48 medical personnel with teams of four basic crews consisting of two flight nurses and three emergency medical technicians. All flight crewmembers received specialized altitude training to become universally qualified to move patients by aircraft. 
Tech. Sgt. Alejandro Rojas, 455th EAES medical technician, said the hardest part about his job is the uncertainty of the missions, but his team trains for the unexpected. “Each of our teams preps and configures all of our equipment the same way,” he said. “That way no matter what aircraft or patients we get, we are ready.”  He also said that even though his unit doesn’t always stay extremely busy, primarily during the winter seasons, the necessity to have them is unquestionable.  “We are like life insurance,” Rojas said.



SOUTHWEST ASIA - Eight members from the 379th Expeditionary Aeromedical Evacuation Squadron transported a patient from a forward deployed location in Southwest Asia, to Landstuhl Regional Medical Center in Germany, Dec. 6, 2013, aboard a C-17 Globemaster III.  The patient, a 54-year-old Army soldier, was suffering from respiratory failure when the aeromedical evacuation crew was notified to transport him to the nearest medical treatment facility. "When we landed near the patient's location, we immediately grabbed all of our medical gear and loaded in the back of a (Army medevac) Black Hawk to get to the pick-up site," said Maj. Matthew Pieper, a 379th EAES critical care air transport team physician deployed from Travis Air Force Base, Calif., and a St. Louis, Mo., native. "Riding in a helicopter was the quickest form of transportation to the patient."
When the CCATT, also including Travis AFB airmen, Maj. Michele Suggs from Flint, Mich., and Tech. Sgt. Athena Sotak from Brownsville, Texas, arrived on scene with the patient, they quickly got him aboard the helicopter, began performing a medical assessment and started a medical ventilator, Pieper said. "Keeping a patient stable in the back of a helicopter is challenging," Pieper said. "There is less space to work, communication is difficult and we had to stay in our seats. We communicated directions with an Army medevac [technician] who was attached to a harness. He had a little more room to move and keep the patient stable." During the helicopter ride back to the C-17, the medical crew swapped out three oxygen tanks to keep the patient breathing through the ventilator. On the third oxygen tank, the patient's oxygen level began to dip as the helicopter was landing, Pieper said. "We ran the patient about 200 yards from the helicopter to the C-17," Pieper said. "The C-17 has more oxygen capacity than the helicopter so we needed to move him as quickly as possible."  Capt. Rebecca Wastart, a 379th EAES flight nurse from Scott Air Force Base, Ill., helped set up the plane to receive the patient said,



These nurses span 13 areas of expertise, 40 years of medical advancements, and all walks of life. Here are their inspiring stories of science and service.  Our 2013 Outstanding Nurses award winners span 13 areas of expertise, 40 years of medical advancements, and all walks of life.  Here are their inspiring—and surprising—stories of science and service.  Mpls.St.Paul Magazine's Outstanding Nurses Awards are given to the top nurses in the Twin Cities metro area. Nurses are nominated by peers, patients, and the general public, and finalists and winners are chosen by an independent panel of judges and Mpls.St.Paul editorial staff.  Along with editorial staff, finalists and winners of the 2013 awards were chosen by two judges with a combined 50 years of experience: Sue Sendelbach, director of nursing research at Abbott Northwestern Hospital, and Michael Petty, cardiothoracic clinical nurse specialist at the University of Minnesota Medical Center.  Nurses are chosen based on professionalism, bedside manner, patient interaction, credentials and experience, impact on an organization, and leadership. Additional weight is given to those who received multiple nominations from multiple sources and to those nominated by their patients.  To nominate a nurse, check back in February 2014, when nominations will open again.    “My leadership with the military, and my age and maturity, transfers into the ER, and my ER experiences transfer into the military. I can’t do one without the other.”  Extra Corporeal Membrane Oxygenation. It’s a mouthful, but it’s one of the incredible advancements Donald Brock has seen as a critical care nurse in the Air Force Reserves.  “While deployed to Germany last year, I witnessed the use of ECMO in a chest wound patient who was shot in Afghanistan,” 
Brock says. A machine oxygenated the soldier’s blood when his heart and lungs didn’t. It took a while, but “several weeks later this young man was sitting up in bed talking to his family as I prepared him for the flight back to the United States.”   Brock was so amazed by the soldier’s recovery that he immediately signed up for the military’s ECMO certification program. Then he shared the procedure with the folks at Regions Hospital (where he also works), who saw potential uses in the emergency room.  It’s all in a day’s work for Brock, who juggles two trauma-related jobs. “As a member of the United States Air Force, I have had the privilege of seeing firsthand how some of the many advances in medicine have saved lives,” he says. Lucky for us, he brings what he learns home.


Dr. Bill Beninati is a critical care physician and a 25 year veteran of the US Air Force.  During his AF career he helped develop the Critical Care Air Transport (CCATT) program and served as a key medical leader in that program for 13 years.  His combat experience includes transports in Bosnia, Afghanistan, and Iraq where he also participated in rotary wing MEDEVAC.  Dr. Beninati now works for the not-for-profit Intermountain Healthcare System, conducts research, teaches medical students as an adjunct faculty member of the University of Utah School of Medicine, and provides leadership as chairman of the team overseeing critical care across the 22 hospital system.


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