In the years following the attacks on Sept. 11, 2001, U.S. Air Force medics accelerated advancements in medical care, specifically aeromedical evacuations, to save more service members’ lives.
The Air Force’s aeromedical evacuation capability is part of a joint medical evacuation system with the U.S. Army. This system allows injured service members to be quickly moved from the battlefield to a theater hospital where they receive additional care until they are ready for aeromedical evacuation. The Air Force’s aeromedical evacuation capabilities have been critical in significantly improving the chance of survival and leading to a record high survivability rate.
According to a 2014 research article published in the Journal of the American Medical Association, the ability for medics to move patients to higher levels of care has played a key role leading to historically low mortality rates compared to previous conflicts. During the Vietnam War, patient movements from the theater to advanced levels of care took approximately 45 days. This time has been reduced to as little as 36 hours.
“One of our key joint capabilities is aeromedical evacuation, and in the last 20 years we have seen rapid advancements of this capability like we have not seen before,” said Lt. Gen. Robert I Miller, U.S. Air Force Surgeon General. “Patients we would have never thought to transport on an aircraft in prior conflicts are now transported with advanced care. The incredible skills of our aeromedical evacuation and specialty teams, and their ability to push our capabilities even further, has saved more lives.”
From rapid advancement in skillsets of medical Airmen to advancements in en route medical technology, aeromedical evacuations have seen a remarkable evolution to ensure more service members can come home safely.
Uniquely capable Airmen
It is obvious the back of a cargo aircraft is nothing like a full-fledged hospital with all the support and materials most medical professionals are familiar with in a brick and mortar hospital or clinic. Despite the difference, Air Force medics are tasked with delivering the same, high-level care in the air as they are on the ground. These medics have to be prepared to treat patients with a wide range of medical concerns and severity of injury.
Air Force medics receive specialized training to expand their expeditionary medical skills and aeromedical skills to work within the challenging environment of an aircraft. Aeromedical evacuation crews have the skills, experience and training to consider the various challenges and limitations to treating a range of patients. Treating injured patients can be stressful at a fully staffed hospital, but aeromedical evacuation crews also deal with loud noises, varied elevation, turbulence, temperatures and limited space.
“We have been able to elevate our training platforms by providing our medical professionals with clinical experience at trauma centers throughout the United States,” said Chief Master Sgt. James Woods, 711th Human Performance Wing’s senior enlisted advisor. “Improvements in medical simulator technology and access to various aircraft trainers have allowed the AFMS to provide top notch medical training and validation. In addition to classroom and simulation labs, we are now also able to run scenarios in almost any environment our medics could see themselves in.”
Woods also explains that advancements in training sharpened the skills of aeromedical evacuation medics, leading to much of the high survival rate seen in the past two decades.
“Experience, increased training and medical advancements have now made it almost routine to fly with patients with certain conditions that 20 years ago would be frowned upon in the en route care community,” said Woods.
The ability to respond to immediate needs was particularly critical during Operation Allies Refuge when Air Force medics worked to get Afghan evacuees out while also attending to a wide range of medical concerns. Medics monitored Afghans who had dehydration and malnutrition. On one flight, one evacuee gave birth shortly before landing.
Adaptability is key for aeromedical evacuation crews and critical care air transport teams. Medics are trained to deliver care on the C-17 Globemaster III, C-130 Hercules, as well as on aircraft usually designated for aerial refueling, like the KC-46 Pegasus and KC-135 Stratotanker.
In July 2020, Airmen assigned to the 931st Air Refueling Squadron and the 22nd Air Maintenance Squadron took part in the KC-46 Pegasus’ inaugural aeromedical evacuation training. This flight included two flight nurses and three medical technicians, who learned how to configure this new aircraft and use their existing aeromedical evacuation skills to provide high quality patient care.
“I have transported patients on multiple airframes to include rotary, small aircraft, large aircraft and other aircraft of opportunity,” said Col. Tory Woodard, U.S. Air Force School of Aerospace Medicine commander. “Throughout my 24-year career, I have seen the rapid increase in our capabilities and the survivability of the complex cases our enroute care teams support. I am continuously impressed by our medics and the amazing things they accomplish.”
Advancements in CCATT
The development of the critical care air transport team, or CCATT, in 1994 enabled the Air Force to bolster its aeromedical evacuation capabilities, allowing more critically ill or severely ill patients to be transported to higher levels of care.
“With about 750 pounds of high-tech medical equipment, the three-person teams…ensure there’s no lapse in care during transport,” said retired Lt. Gen. Charles B. Green, former U.S. Air Force Surgeon General. “The teams speed up the patient movement to increasingly more advanced care.”
Working as highly specialized medics, CCATTs augment aeromedical evacuation teams and essentially turn any cargo aircraft into a flying intensive care unit. Each team includes a critical care physician, a respiratory therapist and a critical care nurse.
According to a 2014 study on Air Force CCATTs, despite having to transport more patients who sustained significant, critical injuries, the en route mortality rate was less than 1 percent. The researchers who published this study explained that the reason for this is the role CCATTs play as a component in the entire continuum of care, from the battlefield to more definitive care.
In 2019, a CCATT embarked on the longest aeromedical evacuation mission, moving a critically injured Soldier more than 8,000 miles, through a combat zone, from Afghanistan to Texas, aboard a C-17 Globemaster III. The CCATT completing this 20-hour, non-stop evacuation required the team to provide continuous monitoring throughout the flight. Additionally, this flight required refueling along the way, adding another challenge to the mission. Refueling during an aeromedical evacuation is uncommon since it can cause additional turbulence, but it was vital for the Soldier to get to specialized care as soon as possible. The strenuous conditions this team worked under to save a Soldier’s life is exactly what they are trained to do.
Expanding the AE Platform
Amid Operation Iraqi Freedom, from 2003 and 2011, patients were often moved in a harsh and high-threat environment. This required a strategic and effective medical evacuation system to ensure patients could move from the point of injury to higher levels of care as quickly and safely as possible.
Patients were transported via Army or Marine Corps helicopter to field clinics where ground medical teams would stabilize the patient for aeromedical evacuation. The Air Force’s aeromedical evacuation crews and CCATTs would move them to theater hospitals and prepare them for a longer flight to higher levels care.
To sustain the amount and type of patients requiring medical evacuation, the Air Force moved away from dedicated aircraft, to aircraft of opportunity. Now, medics are able to use essentially any available cargo aircraft, configured with standardized medical equipment and staffed with medical professionals to provide timely, efficient patient movement.
While intended for cargo, these aircraft are equipped with features that meet the demands of ever-evolving en route patient care.
“We now have access to more airframes that have electrical and oxygen systems that make it easier to transport more patients or higher acuity patients,” said Woods. “Something we wouldn’t have seen 20 years ago.”
Used as a tactical, intra-theater aeromedical evacuation platform, the C-130 Hercules has been described as a workhorse. It is reliable for extensive operations in theater and capable of operations from short and unimproved runways. This allows for medical capabilities to be pushed closer to the front lines. With the ability to access the aircraft’s power and integrate a carry-on oxygen system, the C-130’s cabin design helps reduce the negative impact of altitude on patients.
Faster and more flexible, the C-17 Globemaster III offered medics the ability to bring warfighters to higher levels. The C-17 boasts 77 more feet than the C-130 Hercules and a cruising speed of 515 knots, allowing for the transport of more patients and life-saving medical equipment. Built-in attachments for central oxygen, electric systems lighting and environmental controls on the C-17 helped improve survival rates for even the most critical patients.
With the inclusion of KC-135s in 2003, medics were able to increase the volume of evacuations out of Afghanistan. While these aircraft do not provide the temperature control of C-17s and also require liquid oxygen to be brought aboard, they provide additional capability when operations tempos are high.
Since the KC-46’s inaugural mission on July 10, 2020, Airmen have also been able to transport patients on it. In addition to being able to provide fuel, it also boasts increased lighting, electrical power and storage capacity.
“Aeromedical evacuation experts are involved with the design of new aircraft that will be supporting the aeromedical evacuation mission,” said Col. Kathleen Grimm, chief, Clinical Readiness Operations, En Route Care Training Department, U.S. Air Force School of Aerospace Medicine. “Having input on the KC-46 from the start allowed us to work closely with the larger team and industry partners and ensure its success in supporting these missions.”
A key component to the Air Force’s aeromedical evacuation success is the advancement of medical equipment necessary to monitor and care for patients in flight, especially when transporting a critically ill or injured patient. As mentioned earlier, the back of a cargo aircraft can be noisy, dark, and cramped. The equipment aeromedical evacuation crews and CCATTs use have to work under these conditions.
“My first deployment was in October of 2001 and our equipment sets were extremely heavy for a three-person team, making it challenging to be mobile in an austere environment,” said Woods. “Since then, our equipment and allowance standards have gotten lighter, leaner and more technologically advanced, matching the quality of what our medical professionals use in their military treatment facilities.”
In the earlier phases of Operation Enduring Freedom, medics were seeing patients experiencing injuries impacting their lungs and who were failing on ventilator support. To sustain these critical patients in flight, Air Force medics adapted the use of the existing extra-corporeal membrane oxygenation, or ECMO, machine. ECMO was originally used on infants and children requiring cardiac and respiratory support, but it was not until October 21, 2010, that an ECMO machine was used on an adult. That day, a Soldier with wounds impacting his lungs was transported from Afghanistan to Germany. Now, ECMO, a capability exclusive to the 59th Medical Wing, is fully equipped to deploy globally when needed.
One capability that has been developed to address limited space is the development of a multi-channel wound vacuum system, a device critical to treating trauma wounds. With the multi-channel wound vacuum system, medics can use one device to treat multiple wounds on a patient. This limits the need for multiple devices to be placed on one patient, saving space, power and weight, making it easier to monitor the patient.
Another significant obstacle aeromedical evacuation crews have to work around is noise, making it challenging to communicate. This makes the stethoscope, one of the most recognizable tools of the medical profession, nearly useless on the back of an aircraft. To address this, researchers with the 711th Human Performance Wing, which is part of the Air Force Research Lab at Wright-Patterson Air Force Base, Ohio, are evaluating the use of a digital noise-immune stethoscope. This stethoscope can plug into existing headsets aeromedical evacuation crews already use and would provide them with another capability to monitor their patient.
“Our monitoring devices and other medical instruments have been forced to be more lightweight, durable, and longer lasting than ever before because of the continual demands in deployed environments,” said Lt. Col. Derek M. Sorensen, medical director, Initial In Flight Care Training Division, U.S. Air Force School of Aerospace Medicine. “We continue to advance these with secure interconnectivity and a robust electronic health record to provide safe patient care.”
The COVID-19 pandemic supercharged the need to advance aeromedical evacuation capabilities and procedures to keep both patients and aircrew safe while also mitigating infections.
To begin quickly transporting COVID-19 patients, the Air Force initially relied on a capability that was ready for use, the Transportation Isolation System, or TIS. The TIS was originally developed in 2014 in response to Ebola and the need to be prepared to move patients with a contagious or infectious disease safely.
The TIS was the only one of its kind in the entire Department of Defense, and Air Force medics were trained on procedures for years leading up to the COVID-19 pandemic.
It was not until COVID-19 that the Air Force deployed the TIS on its first operational mission. On April 10, 2020, three patients who tested positive for COVID-19 were transported from Afghanistan to Ramstein. Two TIS modules were placed on the back of a C-17 Globemaster III and manned with a TIS-trained aeromedical evacuation crew and specialty medical team.
While the TIS worked in the initial COVID-19 response, it could only move two to four patients. The reality was that COVID-19 was rapidly spreading and more patients required evacuation. This created a demand for a new solution. After only a few months, the Negatively Pressurized Conex became operational on July 1, 2020, moving 12 patients on its first mission.
The NPC can move up to 28 passengers, 23 ambulatory patients, or eight litters, and is configured for the C-17 Globemaster III and the C-5 Super Galaxy. A smaller variation of the NPC, the NPC-lite, was certified later for the C-130. The NPC proved to be a valuable capability to move patients safely, it mitigated the spread of COVID-19, and allowed for medics to safely monitor and treat patients while in isolation.
“I had the opportunity to work through the first iteration of transitioning from treating infectious patients in place to moving them to get care,” said Grimm. “Working with the design team for the TIS from concept to delivery in six months was amazing. Now to see the advancements to the NPC and NPC-lite, improving upon what we built and the guidance we wrote for the TIS is another example of the evolution of en route care.”
Future of AE
Air Force medics have proved their success and expertise in large-scale conflicts, pushing them to the forefront of en route trauma care. Future contingencies are not likely to look like the ones experienced in the last two decades, and the AFMS continues to look forward and remain ready to adjust its aeromedical evacuation capabilities to meet those needs.
“We need to prepare ourselves to potentially deliver prolonged care in austere environments or be ready to move more patients at once in the future, as we may not always have the ability to rapidly transport patients with the timing and the teams we desire at that exact moment,” said Miller. “So, our aeromedical capabilities need to continue to remain responsive, flexible and ready today for tomorrow’s demands.”