Air Medical Evacuation Research Articles

Surgical challenges in Non-combatant Evacuation Operations

BackgroundGlobal uncertainties have prompted nations to adopt vigilant approaches to safeguard their citizens. Recent crises have compelled Western nations to undertake evacuations, ranging from peaceful scenarios to urgent military interventions. In April 2023, Sudan descended into civil war, prompting France to orchestrate a complex evacuation operation leveraging prepositioned forces in Djibouti. Materials & MethodsThis retrospective observational study aims to analyze the surgical challenges encountered during Operation SAGITTAIRE (OS), focusing on human, technical, and logistical requirements for successful military interventions in multinational civilian populations. ResultsOS successfully evacuated 1017 individuals of 84 nationalities from Khartoum using road, sea, and air routes. Special forces teams, including the Surgical Life-saving Module (SLM), were mobilized alongside conventional military elements. The Joint Medical Surgical Center (JMSC) in Djibouti served as a permanent medical facility with comprehensive facilities and staff. Air Medical evacuations were performed for vicitms and surgical interventions were conducted, including damage control surgery, orthopedic procedures, and debridements. Five surgical evaluations and four surgical procedures were performed. The operation spanned 96 hours without death. The SLM, deployed in Khartoum and within an aircraft, played a crucial role. DiscussionOS highlighted the need for a comprehensive health support system. Challenges in assessing health needs led to the establishment of a substantial and adaptable system. The report emphasizes the importance of a comprehensive approach to support Non-combatant Evacuation Operations in French Doctrine. ConclusionOS showcased the French Health Military Service's capabilities in deploying a comprehensive damage control chain in challenging environments. This fatality-free success underlines the effectiveness of coordinated resuscitation, damage control, and transportation. Evacuation operations in non-combatant settings during civil wars pose formidable challenges, requiring a modular and adaptable support concept. Coordination, communication, logistical preparation, and training are crucial elements for successful management of such operations.

Elevating Prehospital Traumatic Brain Injury Care: A Comparative Analysis of Civilian and Military Air Transport Guidelines

ObjectiveTraumatic brain injuries (TBIs) are a leading cause of death and disability worldwide. Establishing TBI guidelines is crucial for prehospital management. Civilian medical practices are often influenced by military trauma guidelines. This study provides a comparative analysis of prehospital TBI management by a civilian air medical evacuation service using civilian guidelines and military clinical practice guidelines from the Joint Trauma System of the Department of Defense. MethodsA retrospective review of 100 deidentified patient transport logs from a prominent civilian air medical service was conducted. The logs were compared with the service's patient care guidelines and the 2023 Joint Trauma System Clinical Practice Guidelines. Data were analyzed for adherence to 14 metrics. ResultsPatients showed improvement in preflight and postflight Glasgow Coma Scale scores and were managed according to recommendations on head elevation, oxygenation, blood pressure, and temperature by both organizations. Discrepancies between guidelines included differences in the management of ventilator settings, blood pressure, oxygenation, temperature, serum glucose, intracranial hypertension, suspected brain herniation, serum sodium levels, and seizure prophylaxis. ConclusionComparing civilian and military guidelines highlights areas for potential improvements in TBI management, such as integrating advanced monitoring and the implementation of (i-STAT, Abbott Laboratories, Chicago, IL) testing in air transport to enhance patient care and outcomes.

Watercraft as Overwater Ambulance Exchange Points to Enhance Air Medical Evacuation

Ambulance exchange points are preidentified sites where patients are transferred between evacuation platforms while en route to enhanced medical care. We propose a new capability for maritime medical evacuation, which involves co-opting underway watercraft as overwater ambulance exchange points to transfer patients between medical evacuation aircraft. We partnered with the US Army's 25th Combat Aviation Brigade to demonstrate the use of Army watercraft as overwater ambulance exchange points. A manikin was transferred between 2 HH-60M medical evacuation Black Hawk helicopters conducting hoist operations over Army Logistics Support Vessel 3, which was traveling south of Honolulu, HI. The demonstration was enabled by a decision support system for dispatching aircraft, hoist stabilization technology, commercial satellite internet, military geospatial infrastructure applications, and digital medical documentation tools, the benefits of which are all discussed. Three extensions of the overwater ambulance exchange point are introduced, and civilian applications are considered.

Every minute matters: Improving outcomes for penetrating trauma through prehospital advanced resuscitative care.

Prehospital resuscitation with blood products is gaining popularity for patients with traumatic hemorrhage. The MEDEVAC trial demonstrated a survival benefit exclusively among patients who received blood or plasma within 15 minutes of air medical evacuation. In fast-paced urban EMS systems with a high incidence of penetrating trauma, mortality data based on the timing to first blood administration is scarce. We hypothesize a survival benefit in patients with severe hemorrhage when blood is administered within the first 15 minutes of EMS patient contact. This was a retrospective analysis of a prospective database of prehospital blood (PHB) administration between 2021 and 2023 in an urban EMS system facing increasing rates of gun violence. PHB patients were compared to trauma registry controls from an era before prehospital blood utilization (2016-2019). Included were patients with penetrating injury and SBP ≤ 90 mmHg at initial EMS evaluation that received at least one unit of blood product after injury. Excluded were isolated head trauma or prehospital cardiac arrest. Time to initiation of blood administration before and after PHB implementation and in-hospital mortality were the primary variables of interest. A total of 143 patients (PHB = 61, controls = 82) were included for analysis. Median age was 34 years with no difference in demographics. Median scene and transport intervals were longer in the PHB cohort, with a 5-minute increase in total prehospital time. Time to administration of first unit of blood was significantly lower in the PHB vs. control group (8 min vs 27 min; p < 0.01). In-hospital mortality was lower in the PHB vs. control group (7% vs 29%; p < 0.01). When controlling for patient age, NISS, tachycardia on EMS evaluation, and total prehospital time interval, multivariate regression revealed an independent increase in mortality by 11% with each minute delay to blood administration following injury (OR 1.11, 95%CI 1.04-1.19). Compared to patients with penetrating trauma and hypotension who first received blood after hospital arrival, resuscitation with blood products was started 19 minutes earlier after initiation of a PHB program despite a 5-minute increase in prehospital time. A survival for early PHB use was demonstrated, with an 11% mortality increase for each minute delay to blood administration. Interventions such as PHB may improve patient outcomes by helping capture opportunities to improve trauma resuscitation closer to the point of injury. Prospective, Level IV.

Indonesian air medical evacuation: Analyzing readiness and proposing an integrated standard procedure.

Indonesia still faces challenges in providing healthcare services, and it is crucial to develop an air medical evacuation services system for at least two reasons. Firstly, Indonesia is an archipelagic country and a popular tourist destination. Secondly, there are still significant disparities in the number and types of healthcare facilities and health workers nationwide. To respond to the current situation, the healthcare providers and government have made some efforts regarding air medical evacuation but are showing an unintegrated system. This qualitative study aimed to explore the current implementation of air medical evacuation in Indonesia and to propose an integrated standard procedure that all related stakeholders can adopt at the national and regional levels. The study used a multi-case design analysis, collecting both primary and secondary data. Secondary data was gathered through desk studies to learn related policies and previous studies. Primary data was collected through observation and in-depth interviews with relevant stakeholders, including regulators, service providers, practitioners, and non-governmental organizations. The study found that there is currently a regulatory gap for the implementation of air medical evacuation services in Indonesia. The readiness of the Health Human Resources (HHR) is limited in terms of qualification and competency, and the definitive infrastructure of air medical evacuation requires improvement since the providers continue to use the airport for civil transportation. Besides, the interaction pattern between stakeholders needs to be integrated into standardized procedures. Therefore, the study recommends proposing an integrated standard procedure and actionable recommendations to advocate for all stakeholders.

SIMULATED AEROMEDICAL EVACUATION EXACERBATES ACUTE LUNG INJURY VIA HYPOXIA-INDUCIBLE FACTOR 1Α-MEDIATED BNIP3/NIX-DEPENDENT MITOPHAGY.

Background: With the advancement of medicine and the development of technology, the limiting factors of aeromedical evacuation are gradually decreasing, and the scope of indications is expanding. However, the hypobaric and hypoxic environments experienced by critically ill patients in flight can cause lung injury, leading to inflammation and hypoxemia, which remains one of the few limiting factors for air medical evacuation. This study aimed to examine the mechanism of secondary lung injury in rat models of acute lung injury that simulate aeromedical evacuation. Methods: An acute lung injury model was induced in SD rats by the administration of lipopolysaccharide (LPS) followed by exposure to a simulated aeromedical evacuation environment (equivalent to 8,000 feet above sea level) or a normobaric normoxic environment for 4 h. The expression of hypoxia-inducible factor 1α (HIF-1α) was stabilized by pretreatment with dimethyloxalylglycine. The reactive oxygen species levels and the protein expression levels of HIF-1α, Bcl-2-interacting protein 3 (BNIP3), and NIX in lung tissue were measured. Results: Simulated aeromedical evacuation exacerbated pathological damage to lung tissue and increased the release of inflammatory cytokines in serum as well as the reactive oxygen species levels and the protein levels of HIF-1α, BNIP3, and NIX in lung tissue. Pretreatment with dimethyloxalylglycine resulted in increases in the protein expression of HIF-1α, BNIP3, and NIX. Conclusion: Simulated aeromedical evacuation leads to secondary lung injury through mitophagy.

Prone Positioning of Ventilated Patients During Air Medical Evacuation: A Case Series

ObjectiveThe purpose of this study was to investigate patient safety implications of transporting prone-positioned mechanically ventilated patients in the air medical environment (AME). MethodsA retrospective health record review of patient encounters from 2019 to 2021 was conducted using British Columbia Emergency Health Services air medical electronic patient care reports. ResultsA total of 633 patients were identified as intubated, mechanically ventilated, and transported by British Columbia Emergency Health Services air medical teams. Ten patients were identified as having been transported in the prone position. Oxygen saturation, arterial blood oxygen levels, and carbon dioxide measurements from 8 cases indicated that patients remained stable or improved during transport. Cardiovascular episodes including hypotension and tachycardia were observed. In 2 patients, a mean 17.5% decline in oxygen saturation was identified. It could not be determined if this was a result of prone positioning during AME or due to a deteriorating physiological condition related to the patient's underlying disease. There were no identified tube dislodgments during AME transport. ConclusionAlthough proning did not compromise patient safety with respect to tube or line displacement in our study, we cannot draw definitive conclusions regarding the safety implications of proning on patient vital signs during transport.

Features of the organization and implementation of intensive care in seriously injured with burns during the air medical evacuation

Relevance. The problem of organizing and providing emergency medical care during the medical evacuation of seriously injured in emergency situations who received burns remains relevant up to the present time. The effectiveness of the intensive care performed at the prehospital stage significantly affects the condition of patients and the outcome of the treatment. A fairly effective and safe way to evacuate victims in critical condition, including those with burns, is the use of air ambulance. At the same time, the preparation and management of patients subject to air medical transportation requires solving a number of problems during the flight.Intention. To analyze the results of the organization and implementation of intensive care over the past 8 years in seriously injured people with burns after emergencies during aeromedical evacuation by a light-class helicopter.Methodology. We analyzed data from the automated information and analytical system “Disaster Medicine of the city of Moscow” of the Moscow Territorial Scientific and Practical Center of Disaster Medicine (CEMP) of the Department of Healthcare of the City of Moscow concerning medical evacuation of patients with burns over the past 8 years (2014–2021). Historical, statistical, analytical methods were used in the study.Results and Discussion. The main causes of thermal injury are fires, which rank third in the number of events and the number of victims, and first in the number of deaths. In the structure of victims with thermal trauma, 26 % were in extremely serious and serious condition, of which 2 % needed artificial lung ventilation and tracheal intubation. Indications and features of artificial lung ventilation with tracheal intubation were determined for victims with thermal burns who were subject to medical evacuation by a light-class ambulance helicopter.Conclusion. Aeromedical transportation of a burn patient with adequate therapy is relatively safe and prognostically more effective compared to other methods of medical evacuation. When using flight crews with little experience in providing emergency medical care to victims with large burns, special attention should be paid to resuscitation and maintaining euthermia (maintaining human body temperature).

Medical transportation and the contribution of air medical evacuation in isolated mountainous areas of Greece — Case study, Municipality of Agrafa

Medical transportation and the contribution of air medical evacuation in isolated mountainous areas of Greece — Case study, Municipality of Agrafa

Air Medical Casualty Evacuation in High Altitude: An Experience of 100 Cases in High Altitude and Hilly Terrain of Northern India

Objectives: This article describes the on ground challenges faced by the medical care team deployed for transferring critically ill patients by air from remote locations of the high altitude and hilly terrain to definitive health care facility. Methods: All intubated critical patients requiring definitive and super specialty medical care, transferred by air from high altitude hilly terrain to tertiary care hospital during Jan 2016 to Dec year 2020, analyzed in this retrospective study. Results: The total duration of flight was between 40 – 150 min and average being 83 min. Twenty four patients were transferred by fixed wing aircraft and rest 76 by helicopters. All patient were given sedation in form of injection fentanyl 1mcg/kg in dividing doses and boluses of propofol 10 mg intravenously during transfer. The most common change noticed was fall in oxygen saturation with incidence almost 100% of the patients. The mean fall in saturation was 17.29%. Four patients required injection atropine for bradycardia which resulted with decrease of Saturation of peripheral oxygen (SpO2). Conclusion: Transferring a critically ill patient by road to distant medical centers is often not an option because of losing the golden hour of the medical care. Here comes the importance of aeromedical evacuation for a timely transfer for early medical attention. But shifting the critical patients through aerial mode requires planning and poses a variety of challenges. Keywords: Air­evacuation, High altitude, Air ambulance

Strategi Pemilihan Pesawat Angkut Militer Produksi PT. Dirgantara Indonesia Untuk Mendukung Industri Pertahanan Dalam Negeri

Indonesian Navy flights as an integral part of the SSAT have several functions, one of which is to provide rapid logistical support. Based on considerations of function and mobilization capabilities, medium-sized military transport aircraft are the main choice in providing rapid logistical support. The advantages of this function and mobility also make military transport aircraft capable of carrying out additional tasks assigned to their guiding squadron, namely the 600 Air Wing Squadron. The additional tasks are Search and Rescue (SAR), Air Medical Evacuation (EMU) and VIP Flights. Currently, there are 11 elements of the NC212-200 aircraft owned by Puspenerbal, with a description of 7 active elements, 4 disposal processes. In 2017, Puspenerbal received the Beechcraft King Air 350i light transport aircraft, but several operational requirements were not met to carry out the main function as an element of fast logistics support provider, so this element was prioritized to carry out additional functions such as VIP flights. The results of the analysis using the Analytic Hierarchy Process (AHP) method with the help of the Expert Choice 11 Application show the weight of the criteria for selecting medium military transport aircraft, namely Navigation and Communication Equipment 46.4%, Short Take-off and Landing (STOL) Ability 31.7 %, Transportability 15.3%, and Flying Ability 6.7% with an Inconsistency value of 0.07. This shows that the calculation of the correspondent is still within the inconsistency threshold, which cannot be more than 0.1. While the order of priority for the alternative types of medium military transport aircraft from high to low is the CN 295 type 80.5% and the Alenia C27J Spartan type 19.5%. Based on this value, it can be seen that the CN 295 Medium Military Transport Aircraft is the right alternative to be chosen.

Level of Onboard Care for Critical Patients: Analysis of the French Armed Forces Air Medical Evacuations From the Sahel Since 2013

ObjectiveSince 2013, the French Armed Forces have been engaged in the Sahel. The aim of our work was to study the characteristics of severe patients evacuated according to the composition of the air medical staff (ie, an anesthesiologist/intensive care physician [AICP] or an emergency physician [EP]). MethodsThis was a retrospective cohort analysis including all French service members repatriated from the Sahel with a speedy evacuation priority between 2013 and 2019. ResultsA total of 191 patients were evacuated. The causes were trauma for 103 patients and disease for 88. Trauma patients included war injuries (n = 58) and nonbattle injuries (n = 44). For disease patients, the main pathologies were cardiovascular (n = 17), infectious (n = 17), neurologic (n = 15), and gastrointestinal (n = 12). Highly dependent patients were significantly (P < .001) more likely to be managed by an AICP (n = 41) than an EP (n = 5). Moderately dependent patients managed by an AICP (n = 51) were more frequently unstable hemodynamically (n = 5 vs. n = 0, P < .05) and referred to an intensive care unit (n = 24 vs. n = 2, P < .001) than those managed by an EP (n = 41). There were no deaths in flight. ConclusionGreater use of EPs, especially for transporting stabilized patients, would provide more personnel trained in long-distance air transport.

Risk Analysis by Failure Modes, Effects and Criticality Analysis and Biosafety Management During Collective Air Medical Evacuation of Critically Ill Coronavirus Disease 2019 Patients

In March 2020, coronavirus disease 2019 (COVID-19) caused an overwhelming pandemic. To relieve overloaded intensive care units in the most affected regions, the French Ministry of Defence triggered collective air medical evacuations (medevacs) on board an Airbus A330 Multi Role Tanker Transport of the French Air Force. Such a collective air medevac is a big challenge regarding biosafety; until now, only evacuations of a single symptomatic patient with an emergent communicable disease, such as Ebola virus disease, have been conducted. However, the COVID-19 pandemic required collective medevacs for critically ill patients and involved a virus that little is known about still. Thus, we performed a complete risk analysis using a process map and FMECA (Failure Modes, Effects and Criticality Analysis) to assess the risk and implement mitigation measures for health workers, flight crew, and the environment. We report the biosafety management experienced during 6 flights with a total of 36 critically ill COVID-19–positive patients transferred with no casualties while preserving both staffs and aircraft.

Descriptive Analysis of Coronavirus Disease 2019 Air Medical Evacuations by Critical Care Air Transport Teams

ObjectivePreserving air medical evacuation capabilities for critically ill patients with coronavirus disease 2019 (COVID-19) required innovation for en route care logistics, training, and equipment. The aim of this study was to describe characteristics and in-flight interventions for patients with suspected COVID-19 requiring air medical evacuation by US Air Force critical care air transport teams (CCATTs). MethodsWe performed a retrospective chart review of patients with suspected COVID-19 requiring air medical evacuation by CCATT from April 2020 to February 2021. We included patients with an available CCATT medical record and transport with COVID-19 infection isolation precautions. CCATT medical records were the data source, and we performed descriptive analyses of patient characteristics and in-flight interventions. ResultsWe reviewed 460 records and identified 16 patients for inclusion. The Transport Isolation System (50%) and Negatively Pressurized Conex (31%) were commonly used portable biocontainment units. The median patient age was 48.5 years, and 94% were male. All patients required oxygen supplementation, with 8 (50%) receiving mechanical ventilation. In-flight interventions among intubated patients (n = 8) included vasopressors (50%), paralytics (25%), and patient-ventilator asynchrony management (63%). ConclusionPatients with COVID-19 requiring CCATT transport were older than prior military en route care cohorts, and in-flight interventions for patient-ventilator asynchrony were commonly required during mechanical ventilation.

Advantages and disadvantages of using helicopters for air medical evacuation of victims with traumas (literature review)

Relevance. To date, there are no clear criteria and optimal logistic conditions for the use of helicopters for the air medical evacuation of injured victims from the scene and from the emergency zone.Intention. To consider modern scientific views on the problem of using helicopters for air medical evacuation of victims from the place of injury.Methodology. PubMed database and eLIBRARY.ru platform were searched for publications from 2015 to 2020.Results and Discussion. The advantages of air ambulance evacuation by helicopters include shorter prehospital time, delivering victims from hard-to-reach areas directly to high-level trauma centers, and provision of extended prehospital care by highly qualified air medical teams. The use of helicopters is associated with risks to the life of the crew, requires significant financial costs and special equipment, and is limited by the lack of landing sites, weather conditions and at night. The effectiveness of the use of air ambulance helicopters depends on geographic and demographic factors, the level of injuries, the state of the road network in the region, the remoteness of ambulance stations, helicopter bases and trauma centers, the degree of interaction between rescue services and hospital specialists.Conclusion. The evacuation of casualties from the scene of the accident by helicopters of medical aviation can significantly reduce mortality in case of severe injuries.

Analysis of European Air Medical Evacuation Flights of Coronavirus Disease 2019 Patients

ObjectiveAs part of the humanitarian response to the coronavirus disease 2019 (COVID-19) pandemic, the German and French Armed Forces provided air transport for patients from overwhelmed regional hospitals in Italy and France. The objective of this study was to analyze the characteristics of the missions and the medical conditions of COVID-19 patients transported during an air medical evacuation on fixed wing aircraft in March and April 2020. MethodThis was a retrospective analysis of transport records as well as other documents for 58 COVID-19 patients requiring artificial ventilation. ResultsThe median age of the transported patients was 61.5 years, and 61% of them had preexisting medical conditions. They had been ventilated for a median of 5 days and experienced the first symptoms 18 days before transport. The patients flown out of France had less days of ventilation before flight, a lower end-tidal carbon dioxide level at the beginning of the flight, and a lower Charlson Comorbidity Index. There were also some differences between the ventilation and the flight level flown by the 2 air forces. ConclusionThe intensive care transport of ventilated COVID-19 patients requires highly qualified personnel and appropriate equipment and should be planned appropriately.

Rapid response air medical evacuation by civilian HEMS crew of critical patients during COVID-19 outbreak – First Fixed Points

The Covid-19 emergency requires a shared plan for the longrange helicopter transfer of patients affected by the virus in order to reduce the overload of intensive care units. To date, there is limited peer reviewed literature on aeromedical transport of patients with highly hazardous communicable diseases, most of it is military, and none deals specifically with patients affected by Covid- 19. To meet this need, we propose reference criteria regarding preflight, in-flight and post-flight patient management and helicopter sanitization.

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.

Strategic air medical evacuation of critically ill patients involving an intensive care physician: A retrospective analysis of 16 years of mission data.

Strategic medical evacuation (MEDEVAC) allows airborne repatriation of soldiers injured or sick on missions to their national territory. The aim of this study was to describe the epidemiology of strategic MEDEVAC performed by intensive care physicians (ICP) and to analyze the role of the ICP in the management of critical care situations in flight. All soldiers who had high or medium dependency conditions and who benefited from a strategic MEDEVAC with an ICP on board between 1 January 2001 and 30 November 2017 were included in this epidemiological retrospective study. A total of 452 soldiers were repatriated; the causes of repatriation were either trauma (n=245; 54%) or medical pathologies (n=207; 46%). Two hundred and seventy-six (61%) evacuations were performed within 48h. The median annual number of strategic MEDEVAC with an ICP was 26 [20-32]. One hundred and fifty-five (34%) patients were mechanically ventilated and 103 (23%) received catecholamines. The median SAPS II score was 13 [8-24]. One hundred and seventy-eight adverse events were identified, of which 123 (69%) related to a worsening of the patient's clinical condition and 30 (20%) related to a technical problem. Forty-seven (20%) patients who initially appeared stable worsened during the flight. No deaths occurred on board, however, and no flights had to be diverted due to an uncontrolled care situation. The results suggested that the presence of an ICP ensured a continued high-level care for patients with serious trauma and medical injuries, due to the medical and aeronautical expertise that resulted from the theoretical and practical training of the personnel on board. Based on these results, lessons regarding future MEDEVAC flights could be learned in order to continue to improve patient outcome.

Mass Air Medical Repatriation of Coronavirus Disease 2019 Patients

Recent coronavirus disease 2019 (COVID-19) events have presented challenges to health care systems worldwide. Air medical movement of individuals with potential infectious disease poses unique challenges and threats to crews and receiving personnel. The US Department of Health and Human Services air medical evacuation teams of the National Disaster Medical System directly supported 39 flights, moving over 2,000 individuals. Infection control precautions focused on source and engineering controls, personal protective equipment, safe work practices to limit contamination, and containment of the area of potential contamination. Source control to limit transmission distance was used by requiring all passengers to wear masks (surgical masks for persons under investigation and N95 for known positives). Engineering controls used plastic sheeting to segregate and treat patients who developed symptoms while airborne. Crews used Tyvek (Dupont Richmond, VA) suits with booties and a hood, a double layer of gloves, and either a powered air-purifying respirator or an N95 mask with a face shield. For those outside the 6-ft range, an N95 mask and gloves were worn. Safe work practices were used, which included mandatory aircraft surface decontamination, airflow exchanges, and designated lavatories. Although most patients transported were stable, to the best of our knowledge, this represents the largest repatriation of potentially contagious patients in history without infection of any transporting US Department of Health and Human Services air medical evacuation crews.