1. “DOCTOR ON BOARD – what is the optimum skill-mix in military helicopter casevac?” Lt Col Tom WOOLLEY Surg Lt Cdr Stuart MERCER Surg Cdr Steve BREE Lt Col Douglas BOWLEY

2. Civilian pre-hospital helicopter High profile Charitably-funded Accepted as invaluable by the general population

3. Does it make a difference? Mature urban trauma setting: >1800 patients Comparing airlifted patients and those who were transported by ground emergency medical service (GEMS) with transportation time that exceeded 30 minutes (GEMS > 30 minutes) No significant difference in mortality between the two transport modalities Talving P et al. Helicopter Evacuation of Trauma Victims in Los Angeles: Does it Improve Survival? World J Surg. 2009 August.

4. Military pre-hospital care Helicopters accepted as vital: –terrain –time-lines –hostile action

5. Critical report “In Vietnam, wounded soldiers arrived in hospital within 25 minutes of injury. In Iraq in 2005, that figure is 110 minutes, on Operation Herrick IV, (Afghanistan 2006 ) the average pre-hospital time was seven hours. ” Parker PJ. Damage control surgery and casualty evacuation: techniques for surgeons, lessons for military medical planners. J R Army Med Corps. 2006 Dec;152(4):202-11.

6. Introduction of MERT Dedicated air asset Doctor Flight nurse Paramedics “We are bringing the emergency department forward on to the helicopter”

7. MERT: HERRICK 9 July – Nov 2008 324 missions 429 patients 303/324 [94%] to Bastion Hospital Median patients carried was 1 [range 1 – 13]

8. Nationality of patients 242/429 [56%] were local nationals 150 [35%] were UK forces 37 [8.6%] coalition allies

9. Medical category assigned 95/429 [22%] were assigned category T1 223 [52%] were T2 93 [21.5%] were T3 18 [4%] were dead

10. Mechanism 208 [48%] had received blast injury 109 [25%] had GSW 6 [1.5%] had both blast & GSW 41 [9.5%] were medical 23 [5%] were from MVC 42 [10%] had other diagnoses

11. Flight timings Median time from take off to delivery of casualty: 44 minutes Range [10-183 minutes] Doctor flew on 283/320 [88%] of missions

12. Did the doctor contribute? Of 283 missions, it was thought that the doctor was not required in 219/283 [77%]

13. Of 62 missions where doctor was useful, RSI 28/62 [45%] Provision of analgesia/sedation/ blood products: 21/62 [34%] Chest drain/thoracosotomy: 3/62 [5%] Pronouncing life extinct: 4/62 [6%]

14. MERT: a difficult balance 77% missions doctor was simply a passenger Ground-to-air threat Distance from point of wounding to MERT landing site

15. MERT: a difficult balance 23% missions doctor made +ve contribution Knowing when NOT to intervene Morale effect to troops on ground

16. Summary The MERT is a high value asset which makes an important contribution to patient care. A relatively small proportion of missions require interventions beyond the capability of well-trained military paramedics.

17. Conclusion Casualty care is thought to by presence of a physician Military pre-hospital care should be led by doctors / paramedics