Aeromedical Evacuation System Research Articles

Aeromedical Evacuation, the Expeditionary Medicine Learning Curve, andthe Peacetime Effect.

Organizational proficiency increases with experience, which is known as a learning curve. A theoretical peacetime effect occurs when knowledge and skills degrade during peacetime. In this study, the intertheater evacuation system was examined for evidence of a military learning curve and peacetime effect. Data on medical evacuations from U.S. Central Command occurring between January 1, 2003, and December 31, 2022, were acquired from the TRANSCOM Regulating and Command & Control Evacuation System. Priority mission evacuation time corresponding to peak periods of activity in Iraq and Afghanistan and minimal activity in Afghanistan was analyzed. Any reduction or increase in the delivery time of casualties would be considered a change in proficiency. There was a marginal monthly decline of 0.019 days (27.4 min) to perform a priority evacuation from Iraq (95% confidence interval [CI], 0.009 to 0.028 days, P < .001) and a decline of 0.010 days (14.4 min) from Afghanistan (95% CI, 0.003 to 0.016 days, P = .004) over 40 months from peak monthly average times. There was a monthly marginal increase in priority evacuation average time from Afghanistan of 0.008 days (11.5 min) (95% CI, 0.005 to 0.011, P < .001) between January 2013 and December 2020. The number of monthly evacuations estimated to maintain or improve monthly average evacuation time is approximately 50. An intertheater aeromedical evacuation system increased in proficiency during periods of conflict and declined during relative peacetime. There is evidence of a peacetime effect on intertheater aeromedical evacuation.

Development of recommendations for the creation of organizational and functional model of aeromedical evacuation by expert assessment of existing methods of transportation of wounded and sick from the combat zone

Annotation. The article is about the organizational aspects of aeromedical evacuation by helicopters directly from the war zone. The purpose of the study is to determine the opinions of experts on certain aspects of aeromedical evacuation, which cause a lot of discussion among medical personnel performing aeromedical evacuation from eastern Ukraine, to create, the optimal organizational and functional model of aeromedical evacuation in Ukraine by analysis of this dates. The questionnaire method used to find out the opinions of experts on the existing methods of aeromedical evacuation and possible ways to improve as well as implement them in the organizational and functional model of aeromedical evacuation. The questions of the questionnaire concerned the quantitative and qualitative structure of aeromedical crews and the method of their performance, decision-making process on planning of aeromedical evacuation missions and boarding of the patients, required medical documentation of the aeromedical evacuation process, timing of aeromedical evacuation and its responsibilities. The assessment of the competence of the experts carried out in an objective way, which included a documentary method, which provided for the selection of experts based on their professional characteristics. The optimal quantitative and qualitative composition of aeromedical brigades is established, and the staff of which units they should be included is determined. The optimal method of decision-making process aeromedical evacuation and structure of qualitative and quantitative composition of patients is offered. The best way of infight medical support of the patients in critical conditions and ways to transfer responsibility between doctors have been identified. To create an optimal organizational and functional model, further statistical study of the main indicators of aeromedical evacuation is needed to compare the compliance of the obtained recommendations with the real capabilities of the aeromedical evacuation system.

Peculiarities of aeromedical evacuation of wounded and sick and ways of its improvement based on the experience of anti-terrorist operation and joint forces operation

The article is describing general principles of organization of aeromedical evacuation of the patients by helicopters directly from the battlefield area. The number and nature of casualties caused by military aggression determined the organizational and functional features of aeromedical evacuation from the zone of military conflict. The purpose of the study is to investigate demographic, clinical, chronometric and economic indicators of air medical evacuation from the zone of military conflict and between hospitals within Ukraine to create, based on their global analysis, the optimal organizational and functional model of air medical evacuation in Ukraine. Created database, which filled out from various sources. Leading syndromes grouped the diagnoses with which the patients transported. Method of analysis known as an XmR chart used to study dynamic of the aeromedical evacuation process, which is one tool from a collection of methods known as statistical process control. The aeromedical evacuation system must be able to evacuate a sufficiently large number of stable patients from anywhere on the line of contact, and be flexible to respond in the event of a relatively small number of very unstable patients in the area of hostilities who need to be evacuated quickly enough. The obtained statistics can be useful for short- and medium-term planning of the aeromedical evacuation service. The configuration and operation of aeromedical units always depends on the nature and specificity of the military conflict, but the planning of deployment and determination of requirements of means for aeromedical evacuation should always base on the analysis of previous experience.

The Strategic-Aeromedical-Evacuation-System of the German Armed Forces : Long-distance air transport as achallenge for intensive care nurses

This article presents the German Armed Forces Strategic Aeromedical Evacuation system. The following factors are described in detail: the path of alert, the used aircrafts, the medical equipment, the medical care personnel with its associated training as well as the aeronautical and medical issues. This military system for long haul intensive care transport offers many medical possibilities in critical care repatriations from deployment areas, as well as disaster relief missions. It has been successfully proven in numerous military and civil operations and continues to have high recognition among all military allies until today. Different priorities and readiness levels build the base for flexible use of various aircraft types and associated personnel, so that almost every scenario can be covered. The ever-changing tasks and needs of the German armed forces require constant adjustment of this air transport system. For the specialist nurse the intensive care of apatient during air transport is atechnical and physical challenge.

Strategic Aeromedical Evacuation (AE): Examining Biological and Psychosocial Stress in AE Patients

Aeromedical evacuation (AE) transports a military patients with a variety of medical conditions from foreign theaters back to the United States for medical treatment. Biological (e.g., alpha-amylase, immunoglobulin A, cortisol, blood pressure, and heart rate) and psychosocial stress measures were collected in (N = 36) AE patients upon U.S. arrival and before transport to their final military destinations. Biological stress measures were not significantly related to psychosocial measures. Findings provide an important understanding of stress in the AE population and a foundation from which to evaluate future stress mitigation strategies and gage the need for supportive care in the AE system.

Aeromedical evacuation-relevant hypobaria worsens axonal and neurologic injury in rats after underbody blast-induced hyperacceleration.

Occupants of military vehicles targeted by explosive devices often suffer from traumatic brain injury (TBI) and are typically transported by the aeromedical evacuation (AE) system to a military medical center within a few days. This study tested the hypothesis that exposure of rats to AE-relevant hypobaria worsens cerebral axonal injury and neurologic impairment caused by underbody blasts. Anesthetized adult male rats were secured within cylinders attached to a metal plate, simulating the hull of an armored vehicle. An explosive located under the plate was detonated, resulting in a peak vertical acceleration force on the plate and occupant rats of 100G. Rats remained under normobaria or were exposed to hypobaria equal to 8,000 feet in an altitude chamber for 6 hours, starting at 6 hours to 6 days after blast. At 7 days, rats were tested for vestibulomotor function using the balance beam walking task and euthanized by perfusion. The brains were then analyzed for axonal fiber injury. The number of internal capsule silver-stained axonal fibers was greater in animals exposed to 100G blast than in shams. Animals exposed to hypobaria starting at 6 hours to 6 days after blast exhibited more silver-stained fibers than those not exposed to hypobaria. Rats exposed to 100% oxygen (O2) during hypobaria at 24 hours postblast displayed greater silver staining and more balance beam foot-faults, in comparison with rats exposed to hypobaria under 21% O2. Exposure of rats to blast-induced acceleration of 100G increases cerebral axonal injury, which is significantly exacerbated by exposure to hypobaria as early as 6 hours and as late as 6 days postblast. Rats exposed to underbody blasts and then to hypobaria under 100% O2 exhibit increased axonal damage and impaired motor function compared to those subjected to blast and hypobaria under 21% O2. These findings raise concern about the effects of AE-related hypobaria on TBI victims, the timing of AE after TBI, and whether these effects can be mitigated by supplemental oxygen.

The critical care air transport experience

There have been over 8000 documented patients transported by US Air Force critical care air transport teams (CCATT) since the beginning of US military involvement in Iraq and Afghanistan (Ingalls et al. in JAMA 149:807–13, 2014). As part of the joint service, integrated and multi-tiered aeromedical evacuation system (AES), critically ill or injured service members are transported by CCATT on tactical (short range, within a theatre of operations) and strategic (long range, between theatres of operation) missions. Within the AE system, patients move through five echelons of care, beginning with care at the point of injury and culminating at major military medical centers in the United States. Patients with critical injuries sustained during support of Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) are first transported to Landstuhl Regional Medical Center (LRMC) in Germany where they are further stabilized for transport back to US facilities. Flight times between evacuation hospitals within the theatre of operations and LRMC can be as long as nine hours. During transport, CCATT monitor patients and continue ongoing resuscitation and treatment plans. Teams are equipped and prepared to intervene should emergent care be required. Critical patients transported to LRMC will often undergo further surgery and frequently require ICU level care with CCATT for transport from LRMC back to the USA. During the peak of conflicts in Iraq and Afghanistan, aeromedical evacuation of critical patients from the point of injury back to the US typically took 2–4 days (Dorlac et al. in J Trauma 66:S164–71, 2009). The paradigm of transporting “stabilizing” patients, even those with severe traumatic injuries over transcontinental distances and often just hours after initial damage control surgery, is supported by a 0.02 % en route mortality rate and a 98 % survival rate among individuals wounded in OIF/OEF that are transported back to LRMC (Ingalls et al. in JAMA 149:807–13, 2014). The long-range transport of critical patients in the austere environment of a military aircraft creates unique challenges for the transport team and is a vital part of the evolving globally mobile medical support apparatus. This article describes both the role of Air Force CCATT within the context of the integrated military AES and the CCATT mission experience in the deployed environment. The role of specialized transport teams and the expanding role of CCATT in a variety of noncombat operations will also be discussed.

United Kingdom military aeromedical evacuation in the post-9/11 era.

Recent UK military operations in support of the fight against terrorism have resulted in UK military casualties. Movement of these casualties through the military medical chain requires a highly sophisticated aeromedical evacuation capability with worldwide reach. Recognition of the determinants of evacuation allows development to ensure optimal future configurations of military aeromedical evacuation services. The database recording aeromedical evacuations undertaken by the Royal Air Force was searched to provide demographic and clinical data for evacuations between 1 April 2003 and 31 March 2010. Diagnoses leading to evacuation were categorized according to International Classification of Diseases codes. There were 21,477 medical evacuations undertaken. Analysis demonstrated 85.9% were for men and 86.5% were for military personnel, of whom 72.0% were in the army. The most common reasons for evacuation in military patients were musculoskeletal/connective tissue disorders (N = 9192; 50.0%), trauma (N = 1303; 7.1%), and mental health disorders (N = 1151; 6.3%). The most common reasons for evacuation in nonmilitary patients were musculoskeletal/connective tissue disorders (N = 734; 23.8%), genitourinary disorders (N = 325; 10.5%), and circulatory disorders (N = 255; 8.3%). Nontraumatic diagnoses were the determinants of evacuation in 92.9% of military and 95.1% of nonmilitary patients; 17.8% of trauma patients and 0.5% of nontrauma patients utilized high-dependency care. The UK aeromedical evacuation system must have the capacity to evacuate large numbers of patients with nontraumatic diagnoses, but also the flexibility to accommodate smaller, more variable numbers of higher dependency trauma patients. The military medical chain must continually review the differing requirements of civilian patients transferred within their aeromedical system.

Nontherapeutic laparotomy in American combat casualties: a 10-year review.

The civilian literature has expanded the indications for selective nonoperative management (SNOM) for abdominal trauma to minimize morbidity from nontherapeutic laparotomies (NTLs); however, this treatment modality remains controversial and rare in austere settings. This study aimed to quantify the percentage of NTL and incidence of failed SNOM performed in theater and to define each of their respective intra-abdominal-related morbidities. A retrospective evaluation of all patients who underwent a laparotomy from 2002 to 2011 during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) was performed for patients who survived a minimum of 24 hours. With the use of DRG International Classification of Diseases--9th Rev. procedure codes, a therapeutic laparotomy was defined by the presence of a defined intraperitoneal or retroperitoneal procedure; an NTL was defined by the absence of a defined intraperitoneal or retroperitoneal procedure. Second, patients transferred from North American Treaty Organization Role II to Role III medical treatment facilities to be operated on were deemed failed SNOM. Finally, intra-abdominal complications and mortality were identified for patients undergoing therapeutic laparotomy, NTL, and failed SNOM. Blunt, burn, and penetrating injuries accounted for 38.5% (n = 490), 1.1% (n = 14), and 60.4% (n = 769) of all laparotomies in the OEF and OIF, respectively. Thirty-two percent of all laparotomies performed during the OEF and OIF campaigns were NTL; specifically, the NTL rates in OEF and OIF were 38.2% and 28.6%, respectively. In addition, 31.6% and 32.2% of all penetrating and blunt injury mechanisms resulted in an NTL, respectively. The percentage of all patients identified as failing SNOM was 7.5% (n = 95). The early intra-abdominal complication rate for failed SNOM and for all patients undergoing NTL was 2.1% and 1.7%, respectively. The OIF and OEF combined NTL rate was 32.1%, with an associated 1.7% intra-abdominal early complication rate. The infrequent application of SNOM in a deployed military environment is likely secondary to unpredictable fragmentation trajectories and related blast injury patterns, limited medical resources including computed tomography, and a complex aeromedical evacuation system preventing serial observation. Epidemiologic study, level IV.

En route care patient safety: thoughts from the field.

The purpose of this study was to describe the patient safety culture of en route care in the United States Air Force aeromedical evacuation system. Almost 100,000 patients have been transported since 2001. Safety concerns in this unique environment are complex because of the extraordinary demands of multitasking, time urgency, long duty hours, complex handoffs, and multiple stressors of flight. An internet-based survey explored the perceptions and experiences of safety issues among nursing personnel involved throughout the continuum of aeromedical evacuation care. A convenience sample of 236 nurses and medical technicians from settings representing the continuum was studied. Descriptive and nonparametric statistics were used to analyze the quantitative data, and thematic analysis was applied to the qualitative data. Results indicate that over 90% of respondents agree or strongly agree safety is a priority in their unit and that their unit is responsive to patient safety initiatives. Many respondents described safety incidents or near misses, and these have been categorized as personnel physical capability limitations, environmental threats, medication and equipment issues, and care process problems. Results suggest the care of patients during transport is influenced by the safety culture, human factors, training, experience, and communication. Suggestions to address safety issues emerged from the survey data.

The epidemiology of Critical Care Air Transport Team operations in contemporary warfare.

Critical Care Air Transport Teams (CCATTs) have evolved as a vital component of the U.S. Air Force's aeromedical evacuation system. Previous epidemiological research in this area is limited. The objective of this commentary is to highlight the importance of obtaining robust epidemiological data regarding patients transported by CCATTs. A limited epidemiological analysis was performed to describe CCATT patients transported during Operation Enduring Freedom and the waning months of Operation Iraqi Freedom. CCATT transports for the calendar year 2011 were examined as recorded in the U.S. Transportation Command Regulating and Command and Control (C2) Evacuation System database. As many as 290 CCATT primary patient transport records were reviewed. Of these, 58.6% of patients had multiple injuries, 15.9% of patients had traumatic brain injury, 7% had acute coronary syndromes, and 24.8% of all transports were for nonbattle-related injuries. The most common International Classification of Disease, 9th Edition, Clinical Modification coded injury was bilateral lower extremity amputation (40%). Explosive blasts were the top mechanism of injury for patients requiring CCAT. The distribution of injuries and illnesses requiring CCAT appear to have changed compared to previous conventional conflicts. Understanding the epidemiology of casualties evacuated by CCATT during modern warfare is a prerequisite for the development of effective predeployment training to ensure optimal outcomes for critically ill and injured warriors.

Moving Acupuncture to the Frontline of Military Medical Care: A Feasibility Study

Background: Currently, opioids are the predominately prescribed treatment for wounded warriors being transported by the United States Air Force aeromedical evacuation system. Objective: It is not known whether Battlefield Acupuncture (BFA), a type of ear acupuncture, would be an acceptable and utile therapy for patients and medical staff for pain control in the aeromedical evacuation system. The primary aim of this study was to examine the feasibility of introducing BFA into the aeromedical evacuation system. Design and Setting: This was a feasibility and observational study involving patients with pain who were treated with BFA while being transported by the aeromedical evacuation system from the Landsthul Regional Medical Center (LRMC), in Landstuhl, Germany, to Joint Base Andrews (JBA), in Maryland. Participants: The participants were patients with pain who were being transported from LRMC to JBA and nurses and physicians providing the BFA treatment for these patients. Intervention: The intervention was BFA. Main Outcome Measures: The outcome sought was knowledge of the feasibility and acceptability of BFA trial among the medical staff members and the patients. Results: It was feasible to train nurses without any previous acupuncture knowledge or skills to implement BFA. In addition, medical staff members stated that the trial did not interfere with their preflight duties or during the flight. Patients reported an average pain rating of 4.07 before BFA and pain scores 1 hour post treatment and post flight of 2.17 and 2.76, respectively (p<000.1). Conclusions: BFA is a feasible acupuncture technique to be performed within the aeromedical evacuation system without interfering with operational medical duties. Significant pain relief was experienced by those patients who elected to receive BFA to relieve their pain.

P02.58. The feasibility of integrating ear acupuncture into the aeromedical evacuation system from Ramstein Air Base (Germany) to Andrews Air Force Base (US)

Purpose Recently, military leaders have endorsed the need for holistic, non-pharmacologically based approaches to pain. Acupuncture has been shown to be an effective adjunctive therapy for specific pain conditions; however, acupuncture has occupied only a marginal role in pain management. We investigated what would happen if a simple ear acupuncture procedure was introduced into the medical care delivered in the aeromedical evacuation system to wounded warfighters being evacuated from Germany to the US.

Military aeromedical evacuation, with special emphasis on craniospinal trauma

This brief intends to educate civilian neurosurgeons on the structure and function of the US military aeromedical evacuation (AE) system, with special focus on the role of the military neurosurgeon. It highlights the thought process required to participate as a surgical provider in the AE system. It further clarifies the expanded role the AE system plays in nonbattle evacuation.

A Plastic Surgical Nurse's Military Experience

The author thanks Rachelle Springer for her great editing skills, Marcia Spear in showing how to upload in editorial manager, and Amanda Bailey for converting the pictures to JPEGs. Have you ever entertained the idea of serving in the military? Has your sense of patriotism ever made you feel some regret that you never served your country in uniform? It was this deep spirit of patriotism and my sense of adventure that moved me to take the oath of commitment and to give 22 years of my life in service to our country. This article is my personal experience of serving in the military as a flight nurse and a commander. It provides a brief overview of the aeromedical evacuation system, different job classifications, requirements of a flight nurse, stresses of flight, and the type of aircraft used in aeromedical transport.

Nurses' Role in the Joint Theater Trauma System

Nurses' role within the Joint Theater Trauma System's trauma performance improvement program spans the entire trauma continuum. Nurses serve as trauma nurse coordinators at combat zone medical treatment facilities, flight nurses within the US Air Force Aeromedical Evacuation system, multidisciplinary trauma teams at overseas and stateside military and Veterans Affairs healthcare organizations, and members on trauma video teleconferences. Many of the trauma performance improvement initiatives that have occurred since the Joint Theater Trauma System inception have been led by nurses serving within the trauma continuum and resulted in successful outcomes for patients with polytrauma.

The critical care air transport program

The critical care air transport team program is a component of the U.S. Air Force Aeromedical Evacuation system. A critical care air transport team consists of a critical care physician, critical care nurse, and respiratory therapist along with the supplies and equipment to operate a portable intensive care unit within a cargo aircraft. This capability was developed to support rapidly mobile surgical teams with high capability for damage control resuscitation and limited capacity for postresuscitation care. The critical care air transport team permits rapid evacuation of stabilizing casualties to a higher level of care. The aeromedical environment presents important challenges for the delivery of critical care. All equipment must be tested for safety and effectiveness in this environment before use in flight. The team members must integrate the current standards of care with the limitation imposed by stresses of flight on their patient. The critical care air transport team capability has been used successfully in a range of settings from transport within the United States, to disaster response, to support of casualties in combat.

Eye Trauma Management—OIF Clinical Considerations

Abstract : Deployed ophthalmologists in combat support hospitals in Iraq and Afghanistan, backed by subspecialty care in military medical centers across the country, are continuing to provide eye trauma care to deployed troops and injured civilians via a complex aero-medical evacuation system. Whenever possible this involves cooperation with local resources to provide civilian trauma care and follow-up. In contrast to Iraq which had a developed medical system before this conflict, the deployed ophthalmologist in Afghanistan represents the highest level of surgical eye care in the country and thus must employ a full range of skills to provide local eye trauma care to injured civilians, in addition to coalition combat wounded.

Aeromedical Evacuation: Remembering the Past, Bridging to the Future

Operations Desert Shield/Desert Storm saw the largest mobilization of aeromedical evacuation (AE) assets since the Vietnam War. Ultimately, more than 1,950 AE personnel were deployed to support the medical airlift of personnel. With aircrews based at 17 locations in the region, at its peak the system could move up to 3,600 intratheater and 2,500 intertheater casualties per day. Fortunately, the demand for AE fell far short of predictions. During the period from August 12, 1990, to March 31, 1991, more than 12,500 patients were successfully airlifted using converted cargo aircraft, a concept originally validated in World War II. The authors describe the Operations Desert Shield/Desert Storm AE system and identify the efforts underway to construct a new aeromedical evacuation system capable of meeting the needs of the battlefield of the 21st century.

Military Medicine Has NATO Role in Balkans

MILITARY MEDICAL support is available to the approximately 20 000 US Implementation Force ground troops who are spreading out along North Atlantic Treat Organization peacekeeping corridors in the former Yugoslavia. A US Army medical brigade already stationed in Europe is playing a key role. Other medical resources include the US Navy's shipboard hospital beds and the US Air Force's aeromedical evacuation system. As the US troops began to deploy, President Clinton said there could be incidents with people [associated with various factions of the civil war] who still have not given up their hatred. The White House added that poor roads, severe weather, and millions of still-undetected land mines add to the hazards. While US troops are moving into the northeastern Bosnia area around Tuzla, the 74th Medical Group—Provisional from Wright-Patterson Air Force Base near Dayton, Ohio, has turned over United Nations (UN) hospital facilities at Zagreb, Croatia, to military