Casualty Evacuation Research Articles

(P2-1) Large Civilian Jets Configured for Aeromedical Use: Implications for Disaster Health

BackgroundAustralia is a vast and isolated country and often the only viable option of transporting multiple casualties is using fixed wing aircraft. A number of civilian aeromedical services and the military are responsible for the evacuation of casualties, both nationally and internationally. Due to Australia's increased operational commitments, the military can no longer be expected to provide a rapid aeromedical deployment. This situation, coupled with the limited surge capacity of Australia's civilian fixed wing aeromedical services, highlights the need for Australia to improve preparation and readiness for a large scale civilian aeromedical response.Discussion and ObservationsHistorically, the use of large jets configured for aeromedical use has been exclusively the domain of the military. Yet in recent years the use of large civilian jets configured for aeromedical capability has been suggested as a solution. The purpose of this paper is to explore the role of large civilian jets configured for aeromedical use in the event of a disaster with multiple casualties. This study involved an extensive literature review and an international study tour of aeromedical services that are at the forefront of using large jets in aeromedical evacuation. The findings identified that standard civilian jets can easily be reconfigured for transporting multiple casualties. It is argued that this strategy can be an inexpensive and effective option and should be included in emergency preparedness arrangements. The aim of this paper is to prompt disaster health agencies in Australia to consider the use of a civilian jet system that can be used for a disaster requiring a large scale aeromedical response.

Resuscitation: When Less Is More

Resuscitation: When Less Is More

Chest injuries associated with earthquakes: an analysis of injuries sustained during the 2008 Wen-Chuan earthquake in China

The goal of this study was to analyze the patterns, therapeutic modalities, and short-term outcomes of patients with chest injuries in the aftermath of the Wen-Chuan earthquake, which occurred on May 12, 2008 and registered 8.0 on the Richter scale. Of the 1522 patients who were referred to the West China Hospital of Sichuan University from May 12 to May 27, 169 patients (11.1%) had suffered major chest injuries. The type of injury, the presence of infection, Abbreviated Injury Score (AIS 2005), New Injury Severity Score (NISS), treatment, and short-term outcome were all documented for each case. Isolated chest injuries were diagnosed in 129 patients (76.3%), while multiple injuries with a major chest trauma were diagnosed in 40 patients (23.7%). The mean AIS and the median NISS of the hospitalized patients with chest injuries were 2.5 and 13, respectively. The mortality rate was 3.0% (5 patients). Most of the chest injuries were classified as minor to moderate trauma; however, coexistent multiple injuries and subsequent infection should be carefully considered in medical response strategies. Coordinated efforts among emergency medical support groups and prior training in earthquake preparedness and rescue in earthquake-prone areas are therefore necessary for efficient evacuation and treatment of catastrophic casualties.

Feasibility of Negative Pressure Wound Therapy During Intercontinental Aeromedical Evacuation of Combat Casualties

The objective of this study was to assess the feasibility of utilizing negative pressure wound therapy (NPWT) for the treatment of wartime soft-tissue wounds during intercontinental aeromedical evacuation. Attempts to use NPWT during early phases of overseas contingency operations resulted in occasional vacuum system failures and potentially contributed to wound complications. These anecdotal episodes led to a perception that NPWT during aeromedical evacuation carried a high risk of wound complications and limited its use. As a result, NPWT was not frequently applied in the management of soft-tissue wounds before US casualty arrival in the continental United States (CONUS) for wounds sustained in the combat theaters. Concurrently, early NPWT on the traumatic wounds of host nation casualties not requiring aeromedical evacuation seemed to provide many benefits typically associated with the therapy such as decreased infection rates, earlier wound closure, and improved pain management. On a daily basis, study investigators reviewed the trauma in-patient census at Landstuhl Regional Medical Center, Germany, to identify patient candidates with soft-tissue extremity or torso wounds that required packing. Patient demographics, injuries, and previous wound treatments were recorded. Surgeons inspected wounds in the operating room and applied a NPWT dressing if deemed appropriate. NPWT was continued throughout the remainder of the patient's hospitalization and also during aeromedical evacuation to CONUS. A study investigator escorted the patient during aeromedical evacuation to educate the flight crews, to record the impact on crew workload, and to troubleshoot the system if necessary. Thirty enrolled patients with 41 separate wounds flew from Germany to CONUS with a portable NPWT system (VAC Freedom System; Kinetic Concepts Incorporated, San Antonio, TX). All 30 patients arrived at the destination facilities with intact and functional systems. No significant in-flight complications were identified, impact on flight crew workload was negligible, and subjective feedback from both flight crews and patients was uniformly positive. For 29 patients, the NPWT dressing was replaced (frequently with serial exchanges) during initial surgical treatment in CONUS; the 30th patient underwent delayed primary closure of his right forearm fasciotomy. Receiving care teams reported no complications attributable to NPWT during aeromedical evacuation. NPWT is feasible during intercontinental aeromedical evacuation of combat casualties without an increase in wound complications or a significant impact on air crew workload. Further studies are indicated to evaluate the efficacy of NPWT in combat wounds compared with other wound care techniques.

Advancing Critical Care

Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.

Measuring Critical Care Air Support Teams’ Performance During Extended Periods of Duty

The Royal Air Force (RAF) Critical Care Air Support Teams (CCASTs) aeromedically evacuate seriously injured service personnel. Long casualty evacuation chains create logistical constraints that must be considered when aeromedically evacuating patients. One constraint is the length of a CCAST mission and its potential effect on team member performance. Despite no evidence of patient care compromise, the RAF has commissioned a study to investigate whether CCAST mission length influences performance. Describing and understanding the role of a CCAST enabled fatigue to be defined. Factors essential to studying fatigue were then identified that were used to develop a theoretical model for designing a study to measure the effects of fatigue on CCAST performance. Relevant factors include the patient’s clinical condition, team members’ cognition and vigilance levels, and the occupational aviation environment. Further factors influencing overall performance include the duration and complexity of patient interventions, mission length, circadian influences, and fatigue countermeasures.

Determining How Functional Characteristics of a Dedicated Casualty Evacuation Aircraft Affect Patient Movement and Outcomes

Advances in autonomous aircraft technology are spurring research into the different roles these aircraft could fill. The Office of Naval Research (ONR) is pursuing an Innovative Naval Prototype of an autonomous cargo aircraft in response to a United States Marine Corps Universal Needs Statement. Since the use of such a vehicle to evacuate casualties after delivering supplies is an obvious extension, ONR initiated research into how the functional characteristics of an aircraft such as speed, range, capacity, and number available affect how the aircraft performs as a patient movement platform. To evaluate aircraft functional characteristics we executed experiments with a patient movement simulation that explicitly models treatment, evacuation, and mortality as patients flow from the point of injury through definitive care. The experiments provide data, which was used to develop a response surface model of estimated patient mortality as a function of the casualty evacuation system characteristics. This response surface will be useful for comparing competing systems when currently unknown constraints such as total cost of ownership, volume, area, and weight are applied.

Aeromedical Combat Casualty Evacuation from Vietnam to the Global War on Terrorism: Toward a 21st Century Paradigm Shift in Casualty Management

Aeromedical Combat Casualty Evacuation from Vietnam to the Global War on Terrorism: Toward a 21st Century Paradigm Shift in Casualty Management

The Fitness Continuum: Impact on Military Performance

Power lifting (PL) & middle distance (MD) track performances are distinct points on the fitness continuum. Military performance tasks require a multitude of fitness factors. PURPOSE: Examine the impact of fitness on the performance of two military, field assessments: Simulated Casualty Evacuation Test (SCET) and 5-km, 22.7 kg loaded Ruck-Run (R-R) in four distinct U.S. service academy (SA) groups. METHODS: Male (n=75) U.S. SA, college-age students {Div 1 (MD) track, Div 1 Club (PL), general population (GP), and remedial fitness population (RFP)} were tested during a 3-week period in a controlled, supervised field environment on a SCET and a R-R. 3-Mile Run (3MR), Bench Press (79.5 kg, BP), Cadence Pull-ups, Back Squats (102.3 kg, SQ) were also tested in all but one group. Attire was standardized to include: combat boots, Army-Combat Uniform (ACU), dummy weapon (3.2 kg) and Body Armor (BA; 8.5 kg) for the SCET, and running shoes, ACU and load carrying equipment (22.7 kg) for the R-R. The 5-km R-R course, (out-back route), was generally flat with 8% ascent & descent grade encountered twice. The SCET{400 meter run, immediately followed by a 100 meter 45.5 kg dummy carry (100-MDC)} was conducted on an outdoor/indoor, measured running track. RESULTS: ANOVA revealed for the SCET that MD/PL were significantly faster than GP (p =.004). MD runners were faster in the 400 meter run, slower in the 100-MDC, while being 16.8 kg lighter than the PL, yet there was no significant difference in total SCET time between MD and PL (p=.99). ANOVA revealed for R-R that MD were significantly faster than PL (p =.004) who were significantly faster than RFP (p=.0007). MD athlete's loads were ∼31% vs ∼25% BW compared to the PL. Multiple regression yielded different potent predictors for both SCET and 5-km R-R which was dependent on specificity of training/adaptations (MD vs PL). CONCLUSIONS: For U.S. (SA)-age men, fitness status whether attained via cardiorespiratory or muscular strength/power training, significantly influences performance on a 5-km R-R or a 400 meter/100-MDC simulated casualty evac (SCET) assessment. Specifically, two distinct points on the fitness continuum yielded better results on two military, field assessment methods than either the general or remediated population scores and may serve as predictors of combat functional readiness.

A Personal View – 6 Months in a Fob

General Duty Medical Officers (GDMOs) may deploy within days of completing their Entry Officers Course thereby missing the pre-deployment training undertaken by the Regiment that they join. They can be...

Advancing Critical Care

Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.

Measuring Critical Care Air Support Teamsʼ Performance During Extended Periods of Duty

The Royal Air Force (RAF) Critical Care Air Support Teams (CCASTs) aeromedically evacuate seriously injured service personnel. Long casualty evacuation chains create logistical constraints that must be considered when aeromedically evacuating patients. One constraint is the length of a CCAST mission and its potential effect on team member performance. Despite no evidence of patient care compromise, the RAF has commissioned a study to investigate whether CCAST mission length influences performance. Describing and understanding the role of a CCAST enabled fatigue to be defined. Factors essential to studying fatigue were then identified that were used to develop a theoretical model for designing a study to measure the effects of fatigue on CCAST performance. Relevant factors include the patient's clinical condition, team members' cognition and vigilance levels, and the occupational aviation environment. Further factors influencing overall performance include the duration and complexity of patient interventions, mission length, circadian influences, and fatigue countermeasures.

Morbidity rates on Vanguard Class submarines during nuclear deterrent a retrospective review over 13 years

The submarines responsible for the United Kingdom's nuclear deterrent have carried a junior doctor as their medical officer since the program's inception. The Vanguard Class of submarine carries approximately 150 men and deploys for about 3 months at a time. One of the central tenets of submarine operations is to remain undetected and as such the submarine will only surface in an emergency, which may include the evacuation of casualties. The prime reason for carriage of a medical officer is to mitigate against the need to evacuate personnel for medical reasons. We examined the medical section of the patrol reports submitted upon completion of each patrol over a 13 year period to determine both the rates of medical and dental attendance onboard and also the occurrence of potential medical threats to patrol integrity. The most common reasons for attendance were dermatological and musculoskeletal, consistent with previous studies of this population and working environment. There were few dental cases due to the high rates of dental fitness in the pre-sailing crews. Patrol threatening cases occurred at a rate of approximately 1 per 3 patrols, with acute appendicitis being the most common presentation. This progressed to evacuation at a rate of 1 per 15 patrols, with the successful onboard management in 79% of cases. The junior doctor onboard has limited monitoring equipment and formulary, no diagnostic equipment, basic surgical equipment and no opportunity to seek senior advice, and is therefore reliant on clinical judgement. Despite the limitations placed on the doctor on board these submarines they have proven to be effective in reducing the rate of medical evacuation.

Echelon I Interventions and Triage Are Effective and Concordant With Echelon II Care in Combat Operations

We describe identified injuries, effectiveness of treatment, and triage categories for combat casualties at echelon 1 from April 1 to June 30, 2005 from western Iraq. A total of 133 casualties were evaluated including 12 who were killed in action and 7 who died of wounds. A medic or corpsman treated 75% of the remaining patients, 9% were treated by bystanders, 2% were seen by a physician or physician assistant, and 15% administered self-aid. Most injuries (84%) were blast related. Commonly wounded regions were the head (47%), lower extremities (40%), upper extremities (22%), and back (11%). Common interventions included dressings (37%), splints (8%), and intramuscular morphine (8%). Field triage categories at echelon I and casualty evacuation categories at echelon II were congruent. No significant injuries were missed and there were no detrimental interventions. In conclusion, combat casualties were assessed, treated, and evacuated appropriately by echelon I providers during this time frame.

Enteral Feeding Practices for U.S. Service Members in a Deployed Combat Support Hospital

Evidenced based practice guidelines for nutrition support recommend implementation of early enteral nutrition (EEN) in certain patient populations, including trauma and critical illness. Early enteral nutrition has been associated with immune benefits, improved healing, reduced length of stay, and a trend towards a reduction in mortality. Rapid evacuation of combat casualties across the continuum of care presents challenges to implementing EEN during wartime operations. This is the first study to examine enteral feeding practices for combat casualties during Operation Iraqi Freedom. The study method was a prospective records review of all U.S. military combat casualties evacuated from a Combat Support Hospital (CSH) in Iraq, from 1 November to 31 December 2006. The results of this study suggest that casualties who meet the criteria for EEN are not receiving it at the CSH in theater. Further research is needed to explore the impact of delayed enteral nutrition in the combat casualty.

Research and realization of casualty evacuation model in emergency management system

According to the urgent characteristics of casualty evacuation,this paper established a casualty evacuation mathematical model of multi-disaster places,multi-hospital and multi-patients with the goal of the shortest time.Considering the hospital resource competition of patients,Operation Table Method(OTM) was used to solve the model and realize the goal of the shortest time.The method has been realized on the provincial level information demonstration platform of emergency management,and can deal with different injury types and the patient priorities.With this platform and Geographic Information System(GIS) technology,the method is simulated and the effect is good.

The Stability And Utility Of A Simulated Casualty Evacuation Assessment In United States Service Academy Men

Casualty evacuation is a critical task with no adjustment made to body size, fitness, etc. PURPOSE: Create a user-friendly, field-centric, simulated casualty evacuation test (SCET) which supports a comprehensive combat fitness assessment. METHODS: Male (n=20) U.S. service academy, college-age students were tested during an all-out effort, supervised field environment SCET {400 meter run, immediately followed by a 100-meter 45.5 kg dummy carry (100-MDC)}. Additionally, 5 fitness parameters were also tested {3 Mile Run (3MR) and repetitions in the following: Bench Press (79.5 kg, BP), Cadence Pull-ups, Back Squats (102.3 kg, SQ) and Ankles to the Bar (ATB)}. Subjects performed to the best of their abilities with a partial academic grade based on effort. Standardization of attire (SCET only) was mandated to include: combat boots, Army-Combat Uniform (ACU), dummy weapon (3.2 kg), and Body Armor (BA; 8.5 kg).TableRESULTS: Multiple regression revealed Body Weight (BW) and SQ offered the most potent prediction (adj R2 =.47) to the SCET; both variables were independently significant, while 3MR performance added little to SCET predictability. Further, 100-MDC was the most potent influence on total SCET time (adj R2 =.90). CONCLUSIONS: Performance on a field-centric, 400 meter run followed by a 100 meter 45.5 kg dummy carry is influenced significantly via BM, 102.3 kg SQ performance and overall 100-MDC. Several factors are influential in a SCET in service academy men. Notably, the 3MR was the least significant contributor. Since most military tests don't examine lower body MS, the SCET offers potential in identifying attributes (different than health/fitness parameters) which are necessary for the critical task of military casualty evacuation.

SH11 SURGERY DURING WORLD WAR II IN PAPUA NEW GUINEA – THE KOKODA AND BUNA‐GONA CAMPAIGNS JULY 1942 TO JANUARY 1943

The Japanese took Rabaul in January 1942 and established large naval base operations within the South Pacific. After their naval setbacks in the battle of the Coral Sea (May 1942) and at Midway (June 1942) they planned to capture Port Moresby to control sea routes to Australia. During the months February to July Australian troops were being brought into Port Moresby but there was a lack of medical officers and specialists to service the battalions.The Japanese landed at Buna and Gona on 21st July and pressed on to Kokoda where the defending 39th battalion was without a medical officer. The aged WWI veteran, Dr GH Vernon, who had refused to be evacuated, provided care for the mortally wounded Captain Owen on July 23rd. The Australians were forced to retreat down the Kokoda track until the Japanese advance was halted by disease and lack of supplies in September. Then they were able to advance. During this campaign Douglas R Leslie, not then qualified as a surgeon, operated on the wounded at Myola. Once Kokoda was retaken casualties could be evacuated to the Australian General Hospital in Port Moresby by air. Portable Hospitals were introduced by the Americans for the Buna Gona Campaign.The presentation covers the Japanese campaign, their retreat and resort to cannibalism. It also reviews some of challenges presented by the injuries managed by surgeons DR Leslie, TH Ackland, JM Yeates and Major William L. Garlick of the US 3rd Port Hospital. The casualty evacuation arrangement for each of the 3 forces is discussed.

Prospective Observational Study of United States (US) Air Force Critical Care Air Transport Team Operations in Iraq

Current United States (US) military doctrine emphasizes rapid evacuation of casualties to fixed medical facilities remote from the theater of war. To support this strategy, the Air Force has formed Critical Care Air Transport (CCAT) teams consisting of a physician, nurse, and respiratory therapist. To describe the characteristics of US Air Force CCAT team operations at Balad Air Base, Iraq over a 1-year period. Balad Air Base was the primary collection point in Iraq for patients requiring evacuation outside of the country during the study period. The study authors deployed sequentially to Balad Air Base as CCAT team leaders. All patients transported by the authors were enrolled in the study. Injuries, illnesses, demographics, and in-flight data were collected prospectively. There were 133 patients transported on 61 separate flights between Iraq and Germany. Trauma was present in 65% (87/133) of all patients transported. Lower-extremity injuries were the most prevalent among combat-related trauma patients. Cardiac conditions were the most common diagnoses among the medical patients. Fifty-seven percent of patients were mechanically ventilated. Hypotension was the most common in-flight complication, occurring in 17% (22/133) of patients. No flights were diverted or turned back due to an unstable patient. No patient died during flight or in the 24 h after the flight. US Air Force CCAT teams can safely transport multiple critical patients over long distances while providing intensive care interventions. Medical patients make up over one-third of patients requiring CCAT team transport.

David Christopher White

After house jobs in trauma in the Birmingham Accident Hospital and MRC Burns Unit, David Christopher White returned to Westminster Hospital as resident anaesthetist under Sir Ivan Magill. He then...