Joint Medical Evacuation

by Major Nacian A. Largoza

  An important factor in an army's success is the timely treatment of soldiers injured on the battlefield. To accomplish this, injured personnel must be removed to an area where their wounds can be treated properly. There are two critical junctures in the patient evacuation chain. The first is at the point of injury, where medical personnel acquire the casualty. Here the casualty is triaged, treated, and stabilized for initial evacuation to a medical treatment facility (MTF) that has treatment and surgical capabilities commensurate with the patient's wounds. This is the "golden hour," when trained medical personnel initiate treatment and initial evacuation to prevent loss of life, limb, or eyesight.

The second critical juncture in the medical evacuation process occurs after battlefield ground or air evacuation and treatment and is the follow-on evacuation, when Army medics transfer casualties to the Air Force for movement to the corps rear area or the communications zone. This follow-on evacuation is for casualties who cannot be returned to duty within 48 hours in light divisions or 72 hours in heavy divisions, or whose medical needs exceed the theater evacuation policy or the capabilities of hospitals within the theater of operations. Air Force C-130 and C-9A aircraft are used for intratheater tactical patient evacuation. Aeromedical evacuation-configured Civil Reserve Air Fleet B767's along with C-141 and C-17 transports are used for intertheater strategic evacuation.

In addition to timely evacuation to MTF's that can meet patients' needs, the medical evacuation process also requires trained medical personnel to monitor casualties continuously during transport and to provide care en route. This is what distinguishes patient evacuation from the movement of other precious commodities on the battlefield—trained medical personnel who provide full-time supervision and are prepared to provide medical intervention to ensure the survival of injured soldiers. The U.S. Army is one of the few armies in the world that has dedicated ground and air evacuation platforms designed solely for moving patients and medical assets.

Army medical personnel routinely train for initial patient evacuation and build it into every concept of the support plan. Initial patient evacuation is a critical task in all operations and is addressed in every unit's standing operating procedures and in every commander's plan. It also is built into all rotations at the combat training centers. Though initial patient evacuation is still an imperfect system, Army medics routinely execute this mission with high rates of success. However, medics seldom train on follow-on evacuation from the Army to the Air Force. Once Army medical units master initial patient evacuation, the next challenge is to train them with Air Force personnel on the follow-on joint medical evacuation.

Recently, elements of the 25th Infantry Division (Light) from Schofield Barracks, Hawaii, conducted a 5-day joint medical evacuation exercise, Operation RIMFIRE, with Air Force active and reserve component elements. This rare occurrence—Army medics actually training with Air Force medical units—provided a unique opportunity for all parties involved. This article will share the planning, execution, and most importantly, the joint lessons learned from conducting medical evacuation from echelon II, division-level medical companies to the strategic aerial point of embarkation.

Background and Concept

In July 1998, personnel of the 433d Aeromedical Evacuation Squadron from Kelly Air Force Base, Texas, met with the 25th Infantry Division Medical Operations Center (DMOC) to study the feasibility of conducting a joint medical evacuation exercise on the island of Oahu, Hawaii. Apparently, each service had training needs for which the other service could provide resources. The 25th DMOC, the C/725th Main Support Medical Company (MSMC), and the 68th Air Ambulance Company all needed training on preparing patients for evacuation and transferring them to Air Force transports. Active and reserve units of the Air Force had annual medical training and flight requirements, but they did not have the required ground medical units and casualties that had been treated at the division level for evacuation.

The concept was simple. The Army and the Air Force provided a total of 45 soldiers and airmen to act as casualties. A division medical company would be established at a field site to conduct echelon II medical support, which provides care similar to that provided by an emergency room. The company would respond to a mass casualty situation and request Army rotary-wing evacuation and Air Force assistance. The 25th DMOC would provide the command and control for the operation and role-play as the higher medical headquarters elements. Army air and ground assets would evacuate casualties to a mobile aeromedical staging facility. A Hawaii Air National Guard C-130 aircraft would provide tactical evacuation, and an Air Force C-141 transport would perform strategic evacuation.

Execution

Since this was the first time that many of the participants were working with another service, it was decided to keep this first exercise simple and to use the crawl-walk-run training method. The decision to keep the operation simple ruled out nuclear, biological, and chemical scenarios.

Crawl. Safety is paramount in any military operation, but it becomes a special challenge when the personnel being trained are unfamiliar with another service's equipment and procedures. Based on a risk assessment, a half-day training session on equipment was included in the crawl phase.

Units were given day 1 and the morning of day 2 to establish their sites and conduct precombat checks. The afternoon of day 2 was used to conduct additional safety briefings, classes, and hands-on static load training on each service's evacuation platforms. Each day concluded with an after action review (AAR).

Medics transfer a patient from an ambulance to a Hawaii Air National Guard C-130 aircraft for tactical evacuation.

Walk. The actual exercise started on day 3. The 25th DMOC staff moulaged the casualties using Multiple Integrated Laser Engagement System (MILES) card standards that dictate wound, location, urgency, and data for proper treatment. Moulaging is the process of using stage makeup and wax to simulate injuries consistent with those that could be expected in combat. They then staged the casualties at the mass casualty site, which was located at Dillingham Army Airfield on the northwest coast of Oahu. (See map.)

The call for medical support went to the C/725th MSMC, which provided on-site triage, stabilization, and initial ground evacuation to the company treatment and holding area. Once the casualties arrived at the company area, MSMC medical personnel continued to triage, treat, and prepare patients for evacuation. The MSMC requested an Air Force aeromedical evacuation liaison team to help prepare the casualties for fixed-wing evacuation and to arrange for aircraft. [Note: Generally, the Air Force aeromedical evacuation liaison team mission does not include preparing individual patients for movement.] The 433d Aeromedical Evacuation Squadron exercised command and control over all Air Force assets, provided the aeromedical evacuation liaison team to the MSMC, and established a mobile aeromedical staging facility at the nearest runway.

The mission of the mobile aeromedical staging facility was to act as a transfer point where ground units could deliver stabilized casualties requiring further evacuation by C-130. The facility monitored the medical conditions of the casualties and provided medical intervention as required. The mobile aeromedical staging facility established operations at the nearest C-130-capable runway, which was at Wheeler Army Airfield in central Oahu, and prepared to receive and process casualties from the MSMC.

Casualties were moved to the mobile aeromedical staging facility by air and ground. The 68th Air Ambulance Company provided helicopters that transferred the more urgent casualties from the MSMC to the mobile aeromedical staging facility. The MSMC provided the ground evacuation vehicles that moved the less critical casualties. There were two crucial requirements here: first, all of the casualties had to be treated and stabilized before initial evacuation and transfer to the mobile aeromedical staging facility; second, the medics in the ground and air evacuation vehicles had to provide care en route—a key part of the evacuation process.

Once the casualties arrived at the mobile aeromedical staging facility, personnel there re-triaged each individual; checked his bandages, splints, IV's, or other medical paraphernalia; and began preparing him for C-130 evacuation. Once all the casualties were prepared, they were organized by evacuation priority and held in the facility under medical supervision until the aircraft arrived. The mobile aeromedical staging facility arranged to have a critical care air transport team present. The team's mission was to help prepare the most serious casualties for evacuation and provide them with medical care during the flight.

The Hawaii Air National Guard provided a C-130 configured for medical evacuation from Wheeler to Hickam Air Force Base, and casualties were loaded in approximately 15 minutes under a realistic "engine-running-onload" with the aircraft's propellers turning. Under strict ground controls, Army ambulances actually backed up to the C-130 tail ramp to offload patients.

The final leg of the exercise occurred at Hickam Air Force Base. Upon landing, the C-130 parked perpendicular to a C-141 idling on the tarmac. Patients were transferred from tactical to strategic evacuation platforms by "hot tail-to-tail" patient transfer. Casualties requiring additional treatment before being transferred to the C-141 were treated and further stabilized at an aeromedical staging facility that was located in a fixed hangar.

Run. Day 4's schedule of events was similar to that of day 3. However, the speed of the exercise was increased and the locations and wounds of the casualties were modified. Another difference was that the evening AAR was held at the strategic aerial point of embarkation at Hickam Air Force Base. This enabled Army personnel to observe the transfer of patients for the final evacuation leg "out of country."

The mass casualty exercise was staged at Dillingham Army Airfield. Patients were transported to Wheeler Army Airfield by ambulance or helicopter, transferred to a C-130 aircraft and flown to Hickam Air Force Base, and transferred again to a C-141 aircraft for movement "out of country."

Day 5 was the recovery and AAR for the entire exercise. Representatives from all participating units conducted a thorough AAR. An important aspect of day 5 was allowing Army and Air Force ground medical personnel to act as casualties and be loaded into the C-130 aircraft. The goal was to give the ground medics a patient's perspective of the evacuation process and a better appreciation of the patient's experience.

Lessons Learned

Operation RIMFIRE provided a rare opportunity to conduct joint medical training and to highlight strengths in the military healthcare system. In many cases, strengths in the two services' medical systems complemented each other. This was evident in the quality and continuum of care provided by both services as casualties were transferred through the evacuation channels. Operation RIMFIRE also identified unknown weaknesses and highlighted previously identified weaknesses, such as interservice communications.

One of the best lessons learned was that a joint medical evacuation exercise could be conducted at minimal cost to the units involved. For the Army, using units already in the field and medical supplies about to expire minimized costs. For example, the C/725th MSMC was already scheduled to conduct a company field training exercise (FTX) during the dates of Operation RIMFIRE. So RIMFIRE dovetailed nicely with their company FTX and added another dimension to their training. To minimize Air Force costs, reserve component units needing to conduct annual training were used in conjunction with active units. The airframes, aircrews, and in-flight trauma teams task-organized for this exercise all had annual in-flight training requirements. By using these aviation assets, the exercise helped them to meet those requirements without having to ask for additional funding.

While many other lessons were learned by both services, critical lessons learned that will help Army medical units prepare for joint evacuation are—

• Patient classification. The Army and the Air Force use categories to classify patients for evacuation, although the categories may differ slightly. The key lesson learned here is not the difference in terminology, but rather the capabilities gained as patients are transferred from one service to another. In the Army medical system, when a patient's chances of survival on the battlefield are low, he is categorized as "expectant," and minimal resources are expended on him. For example, casualties with cardiac distress are categorized as expectant, and once their pain is relieved, their medical care is the last priority until other, more critical casualties have received care. However, at the mobile aeromedical staging facility, the Air Force critical care air transport team has the capability to provide care to casualties categorized as expectant. These casualties thus have a greater chance for survival. Despite being categorized as expectant, not expected to live, patients actually can survive with rapid transfer to an Air Force critical care air transport team. Although the chances for survival on the ground are low, this team actually can keep these patients alive until they reach an MTF that is able to provide the care they require.
• Medical equipment. The Army medical supply system has converted to the use of nylon litters. Nylon litters facilitate patient decontamination, whereas canvas litters soak up chemical agents. Because patients can slip from smooth nylon litters during take-off and landing, they are not used on Air Force transport. This means that Army ground units evacuating to the mobile aeromedical staging facility cannot conduct litter exchange. This is in keeping with the guidance in FM 8-10-6, Medical Evacuation in a Theater of Operations—Tactics, Techniques, and Procedures, which states, "There is no property exchange of equipment with the Air Force." Many Army ground units are not aware of this. Instead, Army medics must transfer patients physically to Air Force canvas litters and return the nylon litters to their units. While this solves the issue of accounting for medical equipment, it also presents several challenges. This process of exchanging litters is time consuming, and the more a casualty is physically moved the greater are the chances for aggravating his injuries. Thus, Army units must take this physical transfer from litter to litter into account and build ample time into their evacuation plans to allow for this process.
• Patient documentation. At the division level, Army medical personnel primarily use Department of Defense (DD) Form 1380, Field Medical Card, to document injuries and the medical care provided. However, unbeknown to most Army medics, the originating MTF is required to complete three additional forms before Air Force air evacuation. According to FM 8-10-6, "The originating medical facility must complete the following administrative procedures prior to entering the patient into the Theater Evacuation Aeromedical System: the baggage tag (DD Form 600), patient manifest (DD Form 601), and patient evacuation tag (DD Form 602)." [Note: The DD Form 1380 can be substituted for the DD Form 602.] The first lesson learned here is that Army medical personnel at least need to familiarize themselves with these forms and have them on hand in the event of a joint evacuation requirement. The second lesson is that Army units should use the expertise of the aeromedical evacuation liaison team personnel who are pre-positioned with the originating MTF for liaison and communication between the Army and the Air Force. These airmen can show your staff how to complete the forms and, more importantly, can teach the providers how to prepare the casualties for air transportation to reduce further aggravation of their wounds while in flight.
• Communications. This is one area that always presents a challenge to Army units. Communication becomes even more challenging when the operation incorporates a sister service that uses different equipment and procedures. Standard Army medical units have FM [frequency modulated] secure radios and mobile subscriber equipment (MSE). Air Force units primarily use unsecure UHF [ultra high frequency] radios, and their secondary equipment is AM HF [amplitude modulated high frequency] or VHF [very high frequency]. The major lesson here is that Army ground units must request and use the aeromedical evacuation liaison team. Once collocated with an Army activity, the aeromedical evacuation liaison team is the critical bridge for communication between the Army and the Air Force's mobile aeromedical staging facility during joint evacuation.

Operation RIMFIRE was a tremendous experience for all parties involved. There were critical lessons learned at all levels, internal and external, of each participating unit. The low cost of this exercise, achieved by using existing field problems and flight requirements, ensured minimal fiscal impacts on both services. Also, the integration of this exercise into existing field problems and training requirements served to minimize the disruption of customer service or the operating tempo of the units involved. In addition, this exercise served to complement and enhance the already-scheduled training exercises, providing greater depth to the continuum of medical care.

Initial planning and discussion for follow-on exercises in coming years were begun at the final AAR for Operation RIMFIRE. Representatives from the Navy, the Marine Corps, the regional medical center, and others were present in an effort to broaden the scope of future joint evacuation exercises. Given the success of Operation RIMFIRE and the interest and planning for next year, these exercises hold the promise of achieving truly joint medical operations on the modern battlefield. ALOG

Major Nacian A. (Shan) Largoza is the Executive Officer of the 325th Forward Support Battalion, 25th Infantry Division (Light) Division Support Command, Schofield Barracks, Hawaii. When this article was written, he was the Chief of the Division Medical Operations Center. He has a B.S. degree in biology from St. Joseph's University in Pennsylvania and an M.B.A. degree from Syracuse University. He is a graduate of the Medical Officer Basic and Advanced Courses and the Army Command and General Staff College.