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Cover Story November 30, 2006


  Untitled Document

by lyle e davis

Some military medics will shyly say they are simply plumbers. “We plug the leaks, stop the bleeding. Hold the fluids in, and if the helicopter moves fast enough, the wounded warrior wins time to heal.”

Speed is the key. It all happens so fast. A coalition patrol is caught in an ambush, or is the victim of a IED (Improvised Explosive Device), one of the most deadly instruments of war ever devised. The remnants of the patrol immediately retrieve the dead and wounded and call for med-evac.

Usually, a Black Hawk helicopter crew gets the call; they run to the aircraft, the on-board medic checks and doublechecks his gear . . . the litter pans for stretchers . . . oxygen tanks, heart monitors, bandages, bags of saline, all of it ready, wedged into every possible compartment on board. Meanwhile, the pilots start the Black Hawk’s rotors then race through the pre-flight check list. The chopper lifts off and heads off, loud and slow, across the desert, all eyes watching for muzzle flashes, tracers, any hint of an attack that might slow or stall the rescue mission.

Soon, the chopper lets down at the site where the wounded warriors await rescue. Their fellow soldiers have formed a perimeter around the area, scanning the horizon for any additional ambushes, weapons at the ready, prepared to lay down suppressive fire long enough to allow the air-evac to complete its mission.

Four or five troopers race to the chopper with the wounded warriors and frantically shove them inside the aircraft. The medics take over. Sometimes the wounded don’t even have a pulse. CPR begins . . .and the helo lifts off for Baghdad.

Ibn Sina Hospital, Baghdad.

The helo touches down at a landing pad. A nurse and another medic rush to the helo.

The wounded warrior is rushed into a trauma room. Doctors and nurses swarm over him. One continues CPR, others slide tubes into his body, measure blood oxygen levels, monitors beep, it is organized chaos. “I’ve got a pulse!” says one. The helo medic breaks out in a big grin . . . “No one dies in my helicopter!”

The medic returns to his helo. The Black Hawk rescue helicopter and its crew lifts off and heads back to base. There will be other calls . . . and sooner, rather than later.

Meanwhile, our patient’s journey has only just begun. He is wheeled to the operating theatre where shards of shrapnel are removed from his body. Whatever additional surgery that is required is performed. Sometimes this means an amputation . . . sometimes heart -lung surgery . . . sometimes bypass procedures are necessary to access and remove shrapnel. All that can be done is done . . . quickly, efficiently.

Wounded service members having been delivered to a primary resuscitation site are then transported to a larger hospital, perhaps the jointly staffed hospital at Balad Air Base, Iraq. As soon as 30 minutes after surgery, the injured American could be on an airplane headed to Landstuhl, Germany. From there, the injured person may be back in the United States at the military’s National Naval Medical Center (Bethesda, Md.), Walter Reed Army Medical Center (Washington, D.C.) or, in the case of Marines, to Balboa Naval Hospital here in San Diego, or even to Camp Pendleton, three days after the injury.

When an injured service member needs to be moved, the first available aircraft can be readily identified with up-to-the-minute knowledge of where airlifters are. The medical teams and other personnel will already be ready to go.

“There’s a good bit of traffic” in and out of Iraq, noted Maj. Gen. Quentin L. Peterson, AMC operations director, so it is fairly easy to find an available aircraft for an evacuation mission. The airlifters used for evacuations are known as “back-haul” aircraft. The air-evac teams often board aircraft that have just delivered supplies to the forward area, and reconfigure them to carry patients out.

If a C-17 is on final approach when an aeromedical evacuation is needed, airmen would be given prompt instructions, Peterson said. “Clear these three pallets—we’re putting these injured folks on, and by the way, you’re not going to X, you’re going to Ramstein.”

The air-evac teams can quickly convert an airframe for medical use. Typically, the aircrew must load some 800 pounds of equipment and supplies. The loads are standardized, so the air-evac crew is always familiar with what will be aboard: such basic gear as cardiac monitors and oxygen and suction equipment. Fully equipped, the air-evac aircraft has the basic elements of a hospital emergency room, complete with standard medications.

Aeromedical evacuation, led by the Air Force, in recent years has become dramatically more effective. The improvement has a tangible benefit—injured troops are much more likely to survive wartime injuries than they were even in the 1991 Gulf War.
The survival rate for troops injured in Operations Enduring Freedom and Iraqi Freedom is 90 percent. In Operation Desert Storm, only about 75 percent of injured US troops survived their wounds. The survival rate for every other war in the 20th century was between 70 and 80 percent.

Although improvements in body armor, medical treatments, and vehicle protection have undoubtedly contributed to the improved survival rate, the key factor is rapid evacuation. From the moment a soldier is wounded, the rescue system kicks into gear. Aeromedical evacuation plays a key role.

In Desert Storm, it took 10 days to return an injured troop to a stateside medical care facility. Today, even if an injured troop cannot be treated at the massive Landstuhl Regional Medical Center near Ramstein AB, Germany, it only takes three days to return them to the US.

In the past, medical personnel “made sure the patients were absolutely stable before flight, because we were worried we would lose them in the air.” In many cases, injured troops never made it into the airlift system because they died first. Now, the Air Force performs “critical care in the air ... as soon as we can get that person stabilized.”

This mission is performed by highly trained air-evac and critical care air transport teams (CCATTs) . These teams, with portable patient pallets and equipment, can use any mobility aircraft to perform an aeromedical evacuation.

This change in the Air Force’s aeromedical evacuation system sprang not from wartime lessons but from the experience of the Hurricane Katrina relief mission. Under this change, in a matter of hours—not days—this kind of capability can be on the ground in any military theater or for any humanitarian support effort.

By June, more than 13,000 air-med- evac missions have been flown since 9/11, out of Iraq, Afghanistan, and elsewhere— transporting nearly 72,000 patients. About 6,500 battle casualties have been evacuated from Iraq alone.

Air medevacs are not new. They’ve been going on since World War II, but not nearly as efficient as today’s system. During “the old days” where land and sea routes often were lacking C-47s would lift the wounded to general hospitals in New Caledonia, New Hebrides, and Australia. Later, more formal programs began where aeromedical squadrons were formed and trained. Flight crews included a surgeon, nurses, and technicians. In all, more than a million sick and wounded troops were airlifted during World War II.

Early in the Korean War the Military Air Transport Service (MATS) was carrying patients all the way to the US. By the end of that war, air transport was the usual method for moving casualties.

In the past, if an aeromedical evacuation bird was not available, the result was “too bad, so sad.” Well, that’s not the answer we want to give to that injured soldier, sailor, airman, or marine.

Moving Right After Surgery

Prior to the new air-evac procedures taking effect, medical personnel would stabilize the patient for days beforehand until the patient was able to travel. Now, airlift is sometimes being coordinated as a patient is still in surgery on the ground in Iraq. Officials report that “it’s a rare instance that we can’t move a patient. More often, we are taking them right out of surgery and taking them off.”

The air-evac aircraft essentially serves as an en route intensive care unit as the patient is transported to Landstuhl or a stateside medical care facility.

During the Vietnam War, it took an average of 45 days to get a sick or wounded service member back to the States. In the Persian Gulf War and before, ‘we only moved patients who were a week or more post operative and who didn’t have any substantial injuries that hadn’t been fairly well stabilized. Today, things move quickly. Your airway is protected, you’re treated for shock, your extremities are stabilized, and then we put you with your ICU team and fly you back,” officials say. “What we have done is build a system to allow patients to move as soon as half an hour after surgery.” As a result, if you walk through a hospital in Iraq you will see few Americans because most of them have already been airlifted out.

Ready Teams

A typical aeromedical evacuation aircrew today consists of two nurses and three technicians. The critical care air transport teams are separate from the standard air-evac teams and travel with the very critical patients. The CCATTs consist of a physician, a nurse, and a respiratory therapist. They are allowed to handle up to three patients, but do not fly unless a standard air-evac team is also on board, because the CCATTs are not crew members. They are medical support.

Training for the aeromedical teams is exhaustive. In addition to the regular medical course at Sheppard AFB, Texas, graduates must volunteer for the mission, go to flight school, and undergo survival training that teaches them the basics on how to escape, ... evade, and resist capture as a medical crew member. The training regimen takes anywhere from half a year to a year or longer. The crews used to be trained on only one type of airframe. Now, crews are trained on multiple airframes, and this really adds to flexibility. The air-evac crews practice cardiac skills, life support, cardiopulmonary resuscitation, and other basic procedures.

Growing Importance

Aeromedical evacuation is more
important than ever. For starters, the US has troops operating much farther away from home than we have had in the past and farther away from robust health care facilities than in the past. At the same time, if you can take care of your very sick patients ... and feed them into the medical evacuation system within hours or days, you don’t have to have a large hospital forward. You can actually put a number of small hospitals out in the theater and flow a large number of patients through, if you have a solid aeromedical evacuation system. Even when traveling long distances in the back of a C-17, the sickest travel with their own portable ICU, so it is a remarkable bit of teamwork that appears to be going very well. The initial care on the ground is vitally important to the survival of the wounded.

The other military services are responsible for moving their patients to the airfields where they can enter the air evacuation system, which was originally designed to move very large numbers of casualties. Today, the Air Force is moving smaller numbers of patients, but they are frequently in worse shape. The job is an old one, but the new tactics, techniques, and procedures of the aero medical evacuation mission mean the Air Force is now performing it better than ever.

Meanwhile, what happens when the trooper reaches stateside? In the case of Marines you can expect them to be channeled through to Balboa Naval Hospital here in the San Diego area. Or, they may be directed to the Camp Pendleton base hospital, depending upon the extent of their injuries and the facilities needed to treat them.
The nature of the injuries vary. Head injuries account for 33%, arms and hands 40% and legs and feet 37%. Most soldiers receive multiple injuries so the totals above will exceed 100%. What a lot of folks don’t realize is many of the injuries are not visible. Typically, these are head injuries affecting the brain. The concussive effects of explosions will often inflict mild, moderate or severe brain damage that is frequently difficult to initially recognize and more difficult to treat. In fact, the moderate to severe brain damage may not be treatable. The condition has even gotten its own name and acronym . . . TBI (Traumatic Brain Injury).

Once recognized the treatment can be as simple as teaching the trooper how to schedule simple tasks . . . because his brain has forgotten them . . . or forgotten the selection process to make a schedule. More severe brain damage cases can result in violent outbursts of temper, acts of physical violence, senses of smell and touch can be affected.

Finally, the military began to recognize the symptoms and treatment modes for TBI. In fact, there are now four special hospitals run by the Department of Veterans Affairs, all of which specialize in treatment and therapy for brain damaged victims.

Here in North County a local service club, the Hidden Valley Kiwanis Club of Escondido, has become involved with Operation Hero. Each quarter they invite a wounded warrior to be their guest for breakfast, together with the warrior’s spouse and/or children, if available. The warrior’s background is outlined, his military service and the conditions under which he is wounded is outlined. He is then given the opportunity to take questions from the club. At the close of the program the warrior is presented a check for $500 for use as he sees fit.

Most recently, the wounded warrior was presented the check by newly elected Congressman Brian Bilbray. (See photo at bottom).

Left to right, Hidden Valley Kiwanis Club President Richard Jungas, Lyle Davis, Chair of Operation Hero, Marine Corporal Christopher Shelhamer, his wife Amanda, and Congressman Brian Bilbray





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