Guarding America — Defending Freedom The Air National Guard Aeromedical Evacuation Col Charlie Chappuis State Air Surgeon-Louisiana

Flight Surgeon Readiness Skills Verification Requirements 2

Objectives  1. Summarize clearance for aeromedical evacuation  2. Translate physiological knowledge into concrete AE action Guarding America – Defending Freedom 3

Overview  Mission & Function  Area of Responsibility  Organization & Structure  Patient Movement Process/TRAC2ES  Precedence/Classification  Roles and Responsibilities; Risks and Safety  Clinical Considerations/PMR submission  Clinical Decision-aid Tools  Workload and Demographics 4

AE System: Mission and Vision MISSION Move Stable/Stabilized patients with the correct personal and equipment VISION Right Patient, Right Time, Right Place, Right Mode 5

6 AE TERMINOLOGY Aeromedical Evacuation (AE) – is the AF system for moving patients via fixed wing aircraft Medical Evacuation (MEDEVAC) – term used to describe Army’s system for moving patients via rotary aircraft Casualty Evacuation (CASEVAC) – generic term used to describe patient movement regardless of mode of transportation. Unregulated movement

7  INTRATHEATER - TACTICAL  Flying within theater  CENTCOM/CENTCOM  1 day worth of patient medical supplies  INTERTHEATER - STRATEGIC  Theater to CONUS  EUCOM/Andrews AFB  3 days worth of patient medical supplies AE TERMINOLOGY AE TERMINOLOGY

UNCLASSIFED IRAN SAUDI ARABIA ETHIOPIA SUDAN EGYPT JORDAN OMAN BAHRAIN AFGHANISTAN IRAQ QATAR KUWAIT DJIBOUTI PAKISTAN TURKMENISTAN UZBEKISTAN KYRGYZ KAZAKHSTAN KENYA SOMALIA YEMEN UAE TAJIKISTAN ERITREA SEYCHELLES USCENTCOM & NATO OPERATING IN TOUGH AREAS

AIRFRAME INTRATHEATER C-17 C-130 C-21 KC-135 WEAPON SYSTEM = MISSION DESIGN SERIES = AIRCRAFT INTERTHEATER C-17 KC-135 NON- TRADITIONALS C-5, KC-10, B-767 (Civil Reserve Air Fleet)

KC-135

C-17 Globemaster 11

12 USTRANSCOM  Air Mobility Command (AMC) Air component of Patient Movement Lead command for AE Tanker Airlift Control Center (TACC): Executes, Tasks Crews, Controls AMC’s Global Air Missions

PATIENT MOVEMENT REQUIREMENTS CENTERS (PMRC) - Joint activity responsible for patient movement (PM), management, and coordination - Validates PM requests, regulates patients to appropriate medical facilities for continued medical care and determines the mode of transportation (air, ground, or sea)

14 PMRC  GLOBAL PATIENT MOVEMENT REQUIREMENTS CENTER (GPMRC) - Scott AFB, IL  THEATER PATIENT MOVEMENT REQUIREMENTS CENTER (TPMRC) - Ramstein AB GE - Hickam AB HI  JOINT PATIENT MOVEMENT REQUIREMENTS CENTER (JPMRC) - Qatar (SWA)

Patient Movement Area of Responsibility-A Team Effort 15

16 Command/Control of patient movement by air Specialized medical crews and augmentees In-flight equipment En-route facilities on or near flight lines for patient care. AE patient tracking AE PROVIDES

17 AE UTC’s  AE Crew Members (AECM)  Critical Care Air Transport Team (CCATT) Mobile Aeromedical Staging Facility (MASF) Contingency Aeromedical Staging Facility (CASF) Aeromedical Evacuation Liaison Team (AELT) Aeromedical Evacuation Operations Team (AEOT)

Guarding America — Defending Freedom The Air National Guard

Guarding America — Defending Freedom The Air National Guard

Guarding America — Defending Freedom The Air National Guard

FORCE STRUCTURE COMPONENT TOTAL AMC PACAF USAFE ANG AFRES ACTIVE DUTY ARC~90%

Air Evacuation Team  Sets up the plane and crews AE missions  3 flight nurses, 4 medical technicians  Provide in-flight medical care to all AE patients, assist medical attendants Who Cares for the patient? Critical Care Air Transport Team (CCATT)  Provide enroute ICU level care  Physician, ICU Nurse, Resp. Therapist

23 AEROMEDICAL EVACUATION AE MEDICAL CREW: STANDARD o MEDICAL CREW DIRECTOR (Flight Nurse - MCD) o FLIGHT NURSE (FN) o CHARGE MEDICAL TECHNICIAN (CMT) o AEROMEDICAL EVACUATION TECHNICIAN (2 AET) o AEROMEDICAL EVACUATION TECHNICIAN (3 AET) AUGMENTED o FLIGHT NURSE o 2 AEROMEDICAL EVACUATION TECHNICIANS

24 CCATT Critical Care Air Transport Team (CCATT) 3 person team Ready to move when patient is validated needing critical care transport o Not subject to rules and regulations of line flyers Co-located/strategically placed with AE in theater Potential for augmentation with CCATT-E o Adds 2 personnel – 2 CCRN’s with additional PMI/AS to support 5 ventilator patients or up to 10 lower acuity stabilized patients CCATT team chief – usually MD heading CCAT team o Medical authority on board aircraft o Can provide care to other patients during mission if need arises

OIF Patient Movement

OEF Patient Movement

So you need a Patient Movement?  Forward Operating Base:  Use what ever system is in place.  Dust off or land vehicle  Ask questions prior to needing it!  Unstable patients may require a provider to go with them.  If you need fixed wing movement, then who are your friends?  Fellow providers and staff = experience!  Your AE or PAD clerk  Can obtain the 3899 (movement request form)  Will be your liaison to the Joint Patient Movement Requirement Center (JPMRC) at Al Udeid, Qatar (who controls movements)

29 … let’s fly the patient How do we shop for a plane?

30 The Tools ToolFunction TRAC2ES Transcom Regulation and Command/ Control Evacuation System Provides In-transit Visibility (ITV) AF/DD 3899 Provides in-transit record of patient care

31 Key Personnel NameJob Sending Physician Initiates Patient Movement Request (PMR) /AF 3899 Patient Administration Director (PAD) Aeromedical Liaison Team (AELT) Enters PMR in computer (TRAC2ES) PMRC Patient Movement Clinical Coordinator/ Flight Clinical Coordinator Validates patient for movement Provides Nursing Input into Mission planning TACCGets the plane/crew

Patient Movement Precedence  Determines time til mission start, not complexity  URGENT – Move ASAP to save life, limb or eyesight – Goal: start flight within 12 hours of PMR validation – Cargo missions diverted/disrupted (In-System Select/ISS)  PRIORITY – Mission within 24 hours of PMR validation, to move patient to higher care not available locally/to prevent deterioration – ISS is often used; patients with cargo, not instead of cargo  ROUTINE – Movement required, but can wait for a scheduled AE mission – Goal: within 72 hours of PMR validation 32

33 PATIENT CLASSIFICATION Standardized “AE” codes to identify patients who… Must travel on a litter May need help during an aircraft emergency May pose a threat to themselves or others  1A-C – Psychiatric  2A/B – Litter  3A-C – Ambulatory  4A-E - Infant (under 3 years)  5A-F – Outpatient  6A/B - Attendant

Litter v/s Ambulatory  Litter  Medicine patient in a bed  Post-Surgical  Back pain patient  Fractured extremities  Mod/Sev psych patients  Ambulatory  Walkie, Talkies  Mild psych patients  Can tolerate sitting  Can be getting IV fluids/meds

PMR Process AF Form 3899 – Patient Movement Record  Initial patient information completed by physician  Legal record in TRAC2ES  Paper AE Patient Record, travels with Patient  Permanent Medical Record PMR – Patient Movement Request  Based on a completed AF 3899  Primary product of TRAC2ES  Electronic picture of all AE data  ‘Visibility ‘of patient to destination 35

PMR Process  MTF Does AF 3899; submits PMR to JPMRC via TRAC2ES JPMRC sees & validates PMR, send requirements to AECT AECT plans missions to meet time requirement JPMRC manifests patient on mission; notifies MTF of Times MTF/CASF ensure patient is ready for mission and transferred to AE Crew and Plane 36

Validating Flight Surgeon Role  Clinical validation of PMR – determines ‘fitness to fly’ based on PMR clinical information + many phone calls!  Clinically validates all Urgent and Priority PMRs, advises JPMRC Flight RNs on Routines where required.  Validates precedence, classification, in/out-patient.  Provides AE/Av Med advice to clinics, referring Docs – Daily phone calls, weekly , monthly newsletter to all players  Write orders for flight – 02, Rx, alt restrict, stops?, neuro checks, etc  Attending physician for all patients in AE—but never see**  Special requirements? CCATT, Burn Team? 37

Top ½ of AF Form 3899

PMR: Clinical Considerations  History/clinical summary/projected needs in AE  Vital signs, Labs/trends (Hgb, blood gas, CT/x-rays)  Vent settings + O2 sats; trends (no-fly zone>65%FiO2)  Trauma – CT spine cleared, chest, abdomen (FAST)  No trapped air – globe, brain, lungs, sinus, bowel  Drains, chest tubes, NGT/Foley, wound-V.A.C***  Surgeries; windows of risk/opportunity – Date/time out of OR; when completed transfusion – ‘4 hour rule’—stabilized : after surgery/before flight 39

Clinical Considerations Created by NGB/CFX Guarding America – Defending Freedom 40

Bottom ½ of AF Form 3899

ABC’s of AIREVAC Patient Validation  Airway  Normally do not like to fly patients within 24 hours of extubation  Reverse: Do not extubate if flying within 24 hours  Can the airway remain stable for 4-6 hours  If any questions then sedate and intubate!  Breathing  Oxygenation at 8000 ft is impaired for everyone!  If on oxygen = will need more for flight  Recent Cardiac or Surgery = consider adding oxygen (great drug)  Traumatic wounds – O2 may also be analgesic – minimize ischemia

 Circulation  Lower hemoglobin oxygen saturation at 8000 feet  Hgb of 9 g/dl is minimum without oxygen  Hgb of 8 g/dl is minimum on oxygen  Recommend transfuse if Hgb < 8 g/dl  Limits may be lower if anemia is chronic vs acute  Expansion  Wait to Fly > 24 hours after removal of chest tubes (+ Chest xray)  Lower air pressure at altitude (things swell)  Surgery/Trauma = leaky vessels (third spacing of fluids)  Fresh cast need to be bi-valved (possible swelling)  Air in enclosed area (cranium, eyes and ears) “NOT GOOD” ABC’s of AIREVAC Patient Validation

 Fractures  Need to be stabilized (external fixators the best)  Vibration causes pain, possible hemorrhage  Bi-valved cast!!!!  Gastrointestinal  Air within the GI system can cause pain or injury  Consider orogastric or nasogastric tube  Nausea is common on flights = consider antiemetic pre-flight or prn ABC’s of AIREVAC Patient Validation

 Hypo/hyperthermia  Aircraft are climate controlled, but can be cool  Must consider the environment during transport  Hot or cold can be found at various points  Keep patient’s hydrated = IV fluids can be your “friend”  “Jiminies”  Psych patients are a special class of patient!  Might consider chemical and/or physical restraint  Might consider sending a medical attendant  Some are claustrophobic or anxious = consider Valium or Ativan  Balance patient and flight safety with desire to be as little restrictive as possible ABC’s of AIREVAC Patient Validation

PATIENT MOVEMENT  Time from “battlefield” to combat surgical intervention:  Currently: 20 to 75 min  Time from “battlefield” to Landstuhl Medical Center, GE:  Currently: 24 to 48 hrs  Time from “battlefield” to United States facility:  Viet Nam: 45 days  First months of OEF: Avg 8 days  Currently: 2 to 4 days

Questions? 47