DTIC ADA614622: Forward Aeromedical Evacuation: A Brief History, Lessons Learned from the Global War on Terror, and the Way Forward for US Policy

1.1 MB·English

by  Defense Technical Information Center

REVIEW ARTICLE
Forward aeromedical evacuation: A brief history, lessons learned
from the Global War on Terror, and the way forward for US policy
LT Chris M. Olson, Jr., MSC, USN, COL Jeffrey Bailey, MC, USAF, LTC Robert Mabry, MC, USA,
LTCStephenRush,USAF/ANG,MAJJonathanJ.Morrison,RAMC(V),andCAPTEricJ.Kuncir,MCUSN
TheUSArmypioneeredairevacuationofcasualtiesfromthe ambulance system for the US Army. The subsequent emer-
battlefield to a forward operating surgical treatment facil- gence of CASEVAC systems can in part be attributed to the
ity after the advent of the helicopter. This rotary-wing capa- adventof new technologies (enabling safe movementwithout
bility was initially used for casualty evacuation (CASEVAC) sacrificingtheoverallwareffort)coupledwithincreasingsocial
during the Korean War but evolved to the extent that lifesav- activism(callingforcaretothewoundedsoldiers),thelatterof
ing resuscitation was initiated en route by the US Army dur- whichwaspromulgatedbythelikesofHenryDunantandled
ing the Vietnam War. More recently in Iraq and Afghanistan, tothecreationoftheInternationalCommitteeoftheRedCross
medicalevacuation(MEDEVAC)byplatformsoperatingunder and the first Geneva Convention. Until the mid-20th century,
aUSandUKjointsystemhasmatured tothepointwheread- various forms of ground ambulances were used to clear bat-
vancedmedicalcapabilitiesarebroughtforwardtothepointof tlefieldcasualties.Thefirst,butisolated,reportofCASEVAC
injury(POI). accomplishedviaairambulanceoccurredduringWorldWarI
EmergingdatafromtheAfghanistanexperiencehowever when the French used a fixed-wing craft to evacuate Serbian
indicate that clinical and doctrinal gaps exist in US forward casualtiesretreating from Albania.2
aeromedical evacuation(FAME) capability. Inthisreviewarti-
cle,weprovideabriefhistoryofmilitaryMEDEVACcentered The Korean War Experience
ontheevolutionofFAME,describethecurrentFAMEplatforms SoonafterthefirstyearoftheKoreanWar,theArmysent
in Afghanistan, discuss lessons learned from recent studies 12 newly procured Bell H-13 Sioux helicopters to Korea for
examiningtheperformanceofthecurrentFAMEplatforms,and CASEVAC.3 The H-13 had many shortcomings, limiting op-
proposethewayaheadforFAMEinfutureconflicts. erational and clinical functions. Because of the aircraft’s low
power, short range (273 miles), and lack of interior lighting,
FAME EVOLUTION: A BRIEF HISTORY operationswerelimitedtodaylightevacuationofnomorethan
twopatients.Furthermore,owingtotheexternalplacementof
Early Application of Battlefield Evacuation patientlitters,in-flighttreatmentwasnotpossible.CASEVAC
In the first century, the Byzantine Empire’s army incor- wasalsohamperedbyalackofstandardoperatingprocedures,
porated a system for battlefield CASEVAC using medics, lack of a dedicatedcommunications network(the aircraft had
calledScribones,whowerestationedahundredmetersbehind noradios),andlimitedusebecauseofmaintenanceproblems.
the battle and were paid a gold piece for each casualty they Despitetheseshortcomings,helicopterdetachmentsevacuated
rescued.ThereisnorecordoforganizedCASEVACagainuntil asmany as 190,000 casualties.
late in the 18th century when during the French Revolution, Mostimportantly,theKoreanWarexperienceestablished
Napoleon’ssurgeon,BaronDominique-JeanLarrey,rodeinto theroleofthehelicopterinCASEVACandconvincedtheArmy
battleonahorse-drawncarriagetoevacuateinjuredsoldiersto itneeded a permanentorganizationdedicated tothismission.4
the rear of the battle where treatment could be delivered.1 Neartheendoftheconflict,helicopterevacuationdetachments
Before this, casualties were for the most part considered lia- were incorporated into the Army Medical Service, and shortly
bilities to the war effort and therefore were left where they thereafter, the Surgeon General (MG George E. Armstrong)
fell with little-to-no care rendered. During the Civil War in created an organization within the Surgeon General’s Office,
1862, Dr. Jonathan Letterman established the first military capableofdirectingandadministeringaviationresources.5Ad-
ditional planning, personnel staffing, operations and aircraft
Submitted:January31,2013,Revised:March222013,Accepted:April1,2013.
FromtheNavalResearchLaboratory(C.M.O.),StennisSpaceCenter,Mississippi; changesoccurredafterthecease-firein1953.
USArmyInstituteofSurgicalResearch(J.B.,J.J.M.);andSanAntonioMilitary
MedicalCenter(R.M.),FortSamHouston,SanAntonio,Texas;USAFPara- The Vietnam War Experience
rescue (S.R.), Westhampton Beach, New York; and Department of Surgery
(E.J.K.),NavalMedicalCenter,SanDiego,California;andAcademicDepart- The US Army’s 57th Medical Detachment arrived in
mentMilitarySurgeryandTrauma(J.J.M.),RoyalCentreforDefenceMedicine, Vietnamin1962withtheBellUH-1helicopter,whichreplaced
Birmingham,UnitedKingdom.
theH-13in1955.TheUH-1,colloquiallyknownasHuey,had
Theviewpointsexpressedinthisarticlearethoseoftheauthorsanddonotreflectthe
officialpositionoftheUSDepartmentofDefense. twice the speed and endurance of the H-13, carried patient
Addressforreprints:CAPTEricJ.Kuncir,MCUSN,NavalMedicalCenterSan littersin-board,displayedtheGenevaRedCross,anddelivered
Diego,DepartmentofSurgery,34800BobWilsonDr,SanDiego,CA92134; en route careVa first for helicopter FAME. The enhanced
email:[email protected].
flightcrewincludedapilot,copilot,crewchief,andflightmedic.
DOI:10.1097/TA.0b013e318299d189 En route care included application of first aid, morphine
JTraumaAcuteCareSurg
S130 Volume75,Number2,Supplement2
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Report Documentation Page Form Approved
OMB No. 0704-0188
Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington
VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it

does not display a currently valid OMB control number.
1. REPORT DATE 2. REPORT TYPE 3. DATES COVERED
01 AUG 2013 N/A -
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Forward aeromedical evacuation: a brief history, lessons learned from
5b. GRANT NUMBER
the Global War on Terror, and the way forward for US policy.
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
Olson Jr. C. M., Bailey J., Mabry R., Rush S., Morrison J. J., Kuncir E.
5e. TASK NUMBER
J.,
5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
United States Army Institute of Surgical Research, JBSA Fort Sam REPORT NUMBER
Houston, TX
9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S)
11. SPONSOR/MONITOR’S REPORT
NUMBER(S)
12. DISTRIBUTION/AVAILABILITY STATEMENT
Approved for public release, distribution unlimited
13. SUPPLEMENTARY NOTES
14. ABSTRACT
15. SUBJECT TERMS
16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF
ABSTRACT OF PAGES RESPONSIBLE PERSON

a. REPORT b. ABSTRACT c. THIS PAGE UU 7
unclassified unclassified unclassified
Standard Form 298 (Rev. 8-98)
Prescribed by ANSI Std Z39-18
JTraumaAcuteCareSurg
Volume75,Number2,Supplement2 Olsonetal.
administrationforpain,intravenouslyadministeredfluidresus- received a basic medic course and provided only first aid.7
citation,andsurgicalairwayestablishment.Typically,theaircraft Overall, PEDRO fulfilled CASEVAC function far less often
commandertransportedcasualtiestothenearestdefinitivecare than DUSTOFF because it was not their primary mission.
facility unless redirected by the medical regulating officer. In PEDROalsodifferedfromDUSTOFFbyoperatingwithouta
1963, the 57thadopted ‘‘DUSTOFF’’ [DedicatedUnhesitating Red Cross; thus, aircrew wereconsidered combatants.
ServiceToOurFightingForces]astheirradiocallsign,aname The experience and confidence of DUSTOFF and
thathasenduredfor50years. PEDRO units increased throughout the conflict and were con-
DuringtheVietnamWar,theAirForceperformedrotary- sidered an unqualified success during the war; the DUSTOFF
wingcombatsearchandrescue(SAR)andpersonnelrecovery units alone would evacuate nearly 900,000 allied military per-
(PR).ThiswasacontinuationoftheAirRescueService,which sonnel and Vietnamese civilians from the battlefield in Viet-
stood up in 1946, before the 1947 Air Force designation as a nam,8andPEDROwouldrescue4120.9However,inadditionto
separate service, and continued until late 1965 as the Aero- demonstrating its value in the mountains, jungles, and flood
spaceRescueandRecoveryService.Pararescuemen(PJs)were plains of Vietnam, DUSTOFF also demonstrated its vulnera-
best known for being lowered down a hoist torescue isolated bility. Astonishingly, a third of the DUSTOFF aviators, crew
personnel. At about this time, tactical training ensued to per- chiefs, and medics became casualties, and the loss of air am-
mitoperationinhostileenvironments(JohnCassidy,personal bulancestohostilefirewas3.3timesthatofallotherformsof
communication, December 15,2012). helicoptermissionsintheVietnamWar.3Thishighlossrateled
Inthe1950sand1960s,theinitialAirForcehelicopter, toquestioningthevalueofopenlydeclaringthevulnerabilityof
the HH-43 Huskie, was used for local SAR missions around these unarmed platforms with a Red Cross in asymmetrical
bases.In1965,capabilitiesincreasedwiththeintroductionof conflictVa conflict between disparate military powersVin
the Sikorsky HH-3E ‘‘Jolly Green Giant,’’6 and in 1966, which the protection offered by the Geneva Conventions to
‘‘PEDRO’’replacedthecallsign‘‘HUSKIE’’(PEDROwasthe the medical helicopters and personnel were/are not routinely
call sign at Laredo Air Force Base). During this period, PJs afforded.10
Figure1. FAMEplatformsoperatinginSouthernAfghanistanVairframes(left)andinteriorworkingspace(superimposed).Photo
courtesyofEricKuncir,MD;interiorPEDROphotocourtesyofStephenRush,MD;interiorMERTphotocourtesyofJonathan
Morrison,MD.
*2013Lippincott Williams& Wilkins S131
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JTraumaAcuteCareSurg
Olsonetal. Volume75,Number2,Supplement2
TABLE1. FAMEPlatformsOperatinginSouthernAfghanistanVKeyCharacteristics
UnitCallSign DUSTOFF PEDRO MERT
Serviceorganization USArmy USAirForce UKRoyalAirForce
RedCrosssymbol Yes No No
Combatsearchandrescue No Yes No
Helicopter
Airframe UH-60Blackhawk HH-60Pavehawk CH-47Chinook
Cruisingspeed 173mph 183mph 196mph
Armaments None 2miniguns 2minigunsand1M60
Patientlitters 3Y6* 2Y3 8**Y9
Medicalcrew
Physician 0 0 1
Nurse 0 0 1
Paramedic 0 2 2
EMT-B 2 0 0
Enrouteintervention
Activewarming Yes Yes Yes
Intravenousaccess Yes Yes Yes
Intraosseousaccess Yes Yes Yes
Needlechestdecompression Yes Yes Yes
Cricothyroidotomy Yes Yes Yes
Supraglotticdevices Yes Yes Yes
Chesttubeplacement No Yes Yes
Bloodproducts No Yes Yes
RSI No Yes Yes
ACLS No Yes Yes
TXAAdministration No Yes Yes
Videolaryngoscopy No Yes Yes
*Three-litterconfigurationinOEF;maximumofsixwithcarousel.
**AsconfiguredinOEF.
ACLS,advancedcardiaclifesupport;TXA,tranexamicacid.
Post-Vietnam Era Leveraging the success of FAME during the Vietnam
MEDEVACunitsweredeployedseveraltimesinthepost- era, USstateandlocalgovernmentsbegantolookatusingheli-
Vietnam era in support of Operation Urgent Fury in Grenada, coptersincivilianemergencymedicalservicesystems.Throughout
OperationsJustCauseinPanama,andDesertStormandShield the1970sand1980s,civilianhelicopteremergencymedicalservice
inIraq.Duringeachoftheconflicts,combatoperationswere (HEMS) agencies proliferated and became more sophisticated.
over quickly and resulted in few casualties transported by Most adopted a dualprovider model, most commonly a nurse-
MEDEVACunits.ThethreatofwarinEuropepersisteduntil paramedicteam.Theseprovidersarerequiredtohaveadvanced
the SovietUniondissolved in 1991. Large-scalewarin Europe trainingandcertificationsandareexpectedtoprovidecriticalcare
assumed massive numbers of casualties and continued to drive inthehelicoptertoincludeadvancedairwaymanagement,blood
MEDEVAC’sfocusonevacuatingcasualtiesfromthebattlefield. administration,andtheuseofavarietyofpharmacologicagents.
With the historic focus being on battlefield ‘‘clearance,’’ inno- Withtheanticipationoflargenumbersofcasualtiesdur-
vationinprehospitaltraumalifesupportandenroutecarehasonly ing a NATO Soviet conflict and with no prolonged conflict to
recentlybegantoemergeafter10yearsofwarinAfghanistan.11 forceexaminationoftheVietnameralegacymodelofasingle
Inthe1980s,theUSArmybeganphasingouttheUH-1 medic without advanced training, Army MEDEVAC had no
Huey in favor of the faster and larger Sikorsky UH-60 Black reason to adopt the lessons learned from the rapidly evolving
Hawkhelicopter.DuringOperationDesertStorm,USCentral civilian HEMSexperience, which has demonstrated some evi-
Commanddedicated220helicoptersforFAME;75%ofthese dence of improved outcomes with the use of advanced care
were UH-1s, and 25% were UH-60As.12 By the end of the practitioners.14Y17
1990s, the UH-60Awould completely replace the UH-1 with
theexceptionofsomereserveunits.Althoughtheseunitswere
MODERN FAME PLATFORMS
assignedtotheMEDEVACmissionforthe43-dayPersianGulf
War of 1990 to 1991, they were lightly tasked because US Three FAME platforms have been operational in recent
Forces sustained lessthan 500 battle-relatedcasualties during years of Operation Enduring Freedom (OEF) as shown in
theconflict.13 Figure1.Eachplatformwasborneoutofuniquerequirements
S132 *2013Lippincott Williams &Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JTraumaAcuteCareSurg
Volume75,Number2,Supplement2 Olsonetal.
and therefore possesses a distinct combination of on-board prevented launch of a DUSTOFF mission. That same year at
medical and nonmedical capability, as outlined in Table 1. In KandaharAirField,Afghanistan,PEDROwasformallytasked
2009, Secretary of Defense Robert Gates mandated that US withtheFAMEmission,ultimatelyflyingwithGuardianAngel
MEDEVACdeliverbattlefieldcasualtiestoafieldhospitalwith Teams,theAirRescuepackagethatincludesaCombatRescue
appropriate surgical care within 1 hour after the request for a OfficerandfivePJsonapairofHH-60s.
MEDEVAC.ThisisknowncolloquiallyastheGoldenHourRule. Based on these successes and to meet the Golden Hour
Rule, in early 2009, a fragmentation order was given for Air
US Army MEDEVAC: Call Sign ‘‘DUSTOFF’’ Force Air Rescue assets to provide joint PR and MEDEVAC
DUSTOFF has been the most widely used MEDEVAC support going forward.The order added theuseof theC-130
unit throughout the history of US warfare, including during withaGMO-levelflightsurgeonandthreePJswithoutcritical
therecentOperationIraqiFreedom(OIF)andthecurrentOEF. caretrainingwiththecallsign‘‘FEVER.’’Fixed-wingmissions
The current airframe is a UH-60A Blackhawk, distinguished includedpickinguppatientsatforwardoperatingbaseswhowere
bythecharacteristicRedCrosssymbol,andisnotarmedwith often immediately in a postoperative status and on ventilators
offensive weapons unlike the other two platforms. The ratio- withongoingresuscitativeandsedativerequirements.
nality of dispatching unarmed DUSTOFF helicopters with
overtoutwarddesignationbyaRedCrosstohostilefirezones UK MEDEVAC: Call Sign ‘‘MERT’’
inaneraofasymmetricalwarfarehasbeenquestionedsinceits TheUKmedicalemergencyresponseteam(MERT)was
debut in the Vietnam War, yet this important topic is beyond originallydeployedinSouthernAfghanistanin2006;however,
thescope ofthe current review.DUSTOFF unitswenttoIraq its genesis originates in OIF as part of an incident response
and Afghanistan, operating under the legacy model that had team. This rotary-wing asset was designed to quickly deploy
essentiallychangedlittlesincetheVietnamera.Theseaircraft specialist personnel. The medical component consisted of a
were still staffed by a single medic, now credentialed at the GMO delivering a forward extension of UK battlefield ad-
emergencymedicaltechnician-basic(EMT-B)level.Underthe vanced trauma life support.
legacy training model, there was no requirement to partici- Following the UK deployment into Helmand Province
pateinthecareofasinglecriticallyinjuredorillpatientbefore in2006,owingtothelargebattlespace(58,000km2),forward
deployingtocombatasaflightmedic,andtherefore,advanced criticalcarewasrequiredtoreducethetimefromwoundingto
capabilities are limited as shown in Table 1. No standardized thedeliveryofskilledresuscitation.Sinceanumberofdeployed
protocolsexistacrossMEDEVACunits,andmedicaldirection clinicians were trained HEMS providers, a similar model of
wasprovidedinmostcasesbygeneralmedicalofficers(GMO) physician-led prehospital care, involving delivery of advanced
servingwithaviationunits.TheseGMOsgenerallycompleted clinicalintervention,wasinstituted.TheMERThassubsequently
internships and were awaiting placement into residency pro- evolvedintoascalableplatformwherethebasicMERTconfig-
grams.Their primaryjobwastoprovideroutinemedicalcare urationconsistsofanadvancedparamedicornurse,whichcanbe
to the aviators in that unit. No standardized system of patient enhanced as MERT-E with the addition of a physician and in-
documentation, chart review, or process improvement exists. terventionssuchasprehospitalbloodandrapidsequenceinduc-
RotaryMEDEVACunitsaretraditionallycommandedbyavia- tion (RSI), as shown in Table 1. The MERTis not exclusively
torswithnoclinicalexperience,and currently noformal clini- rotary-wingbased,soitcanalsobelittoral,sea,orlanddeployed
cal oversight of MEDEVAC by experts in trauma, emergency This ‘‘militarized HEMS’’ concept has proven contro-
medicalservices,orcriticalcareexists. versial because the asset isof high value and requires signifi-
cant logistic support and limited clinical evidence supporting
US Air Force Expeditionary Rescue Squadron: itsdeploymentexists.Moststudiesareeitherobservationalor
Call Sign ‘‘PEDRO’’ editorial and lack a comparison population. Davis et al.18 in
Throughout OIF and OEF, PJs performed their desig- 2007 reviewed the civilian literature and some unpublished
nated PR mission, occasionally conducted MEDEVAC mis- military outcome data and concluded that a MERT physician
sions in support of the Army, and provided on-scene support improvedoutcomesinmajor trauma.Taietal.19reviewedthe
for special operations serving as both a tactical/technical res- importance of early, skilled resuscitation in critical battlefield
cue specialist and an emergency medical casualty care pro- traumaandpostulatedthattheMERT-Emayservetoextendthe
vider. Their combination of advanced rescue and medical physiologicwindowofsalvage insuch cases.
capabilities define the Pararescue role; being a paramedic is Calderbank et al.20 prospectively examined the quality
only one of their skills. After initial paramedic certification, of the physician’s contribution to MERT over 5 months and
clinical skills maintenance is challenging and occurs at their 324 missions in 2008. A physician flew on 88% of MERT
home station while working to maintain other skill sets re- missions and was felt not to be clinically beneficial in 77%
quired for their mission. Despite this, during the course of ofmissions.However,therewerefewcriticalcasualtiesduring
these conflicts, PJ medical capability has evolved from pro- the study, although RSI was specifically identified as an in-
viding tactical combat casualty care (TCCC) and paramedic tervention that was lifesaving in a small number of casualties
care to a more advanced capability as shown in Table 1. In- with compromised airways.
tubation is generally limited to strict indications and applied Following the deployment of US forces in Helmand
less aggressively than on theUK platform. in mid-2008, UK MERTs started to operate in parallel with
In2007,PEDROoperatingatBagramAirField,Afghanistan, PEDRO and DUSTOFFassets. Integrationof interserviceand
flewMEDEVACinlieuofDUSTOFFwhenweatherconditions multinationalplatformshaspermittedthedeploymentofaunique
*2013Lippincott Williams& Wilkins S133
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JTraumaAcuteCareSurg
Olsonetal. Volume75,Number2,Supplement2
prehospitalsystemofcareinSouthernAfghanistan.Forthefirst (1Y15,16Y50,and51Y75).Thestudydemonstratesthattimes
time, comparison of clinical outcomes between platforms, dis- fromtaskingtoarrivalintheemergencydepartmentweresimilar
cussedinthenextsection,suggeststhatthereisasurvivalbenefit acrossallplatforms,andahighpercentageofthemostseverely
toanadvancedclinicalcapabilityincertainpatientgroups.21,22 injuredpatientsevacuatedwithMERTunderwentanadvanced
However, MERT and MERT-E have only ever operated in intervention.Thelargestproportionofpatientswereinthelowest
combattheaterscharacterizedbyasymmetricwarfarewithair ISScategory,wheretherewasnodifferenceinmortalityacross
superiority.Itisalsounclearhowsuchanassetwouldorcould the platforms. However, casualties in the middle ISS category
performinaconventionalwar,wherethelossofevenasingle were associated with a lower mortality if they were retrieved
MERT-Ecouldsignificantlylimitoperationaleffectiveness. by MERT. ThestudyofMorrison etal. alsoreports a reduced
timefromadmissiontosurgeryintheMERTgroup,attributed
toa combination ofpatient preparednessand directcommuni-
LESSONSLEARNEDINIRAQANDAFGHANISTAN cationbetweentheplatformandreceivinghospital.Overall,this
The killed-in-action and died-of-wounds rates in the re- reportsuggeststhatmortalityfromcertainpatternsandseverity
centIraqandAfghanistanconflictsarethelowestinthehistory oftraumaaredecreasedwiththedeploymentofadvancedmedi-
ofarmedconflict.Eastridgeetal.23analyzingprehospitaldeath calcapabilityaspartofPOIenroutecarecapability.However,it
onthebattlefieldnotedthat88%ofUScombatfatalitiesoccur does not present evidence on which component(s) of this ca-
inthe prehospital phase ofcareand 92% ofthisgroupdiesof pabilitycontributemosttothissurvivaladvantage.
hemorrhage.Whileevidencethatadvancementsintacticalfield AsecondstudybyApodacaetal.22isaUScombattrauma
andfirstrespondercarehascontributedtoimprovedbattlefield registryperformanceimprovementstudycurrentlysubmittedfor
survival has been forthcoming,24 literature that documents the publication.Thestudycohortconsistedof975casualtiesevac-
contribution of advances in evacuation and en route care to uatedbyMERT(n=543),PEDRO(n=326),andDUSTOFF
casualtymortalityrateshasonlybeguntoemerge.Thefollowing (n=106)duringtheshorterperiodofJune2009toJune2011.
discusses studies that illustrate lessons learned from FAME ResultsshowedthatMERTwaspreferentiallytaskedtotransport
operationsinIraqandAfghanistan. polytrauma casualties and also casualtieswith single or multi-
pleamputations.Notsurprisingly,thisstudydemonstratedthat
MERTcasualtieshadonaveragemoresevereinjuriesandworse
DUSTOFF Survival Rates Improve With
shock physiology manifested by lower systolic blood pressure
Paramedic Training
and tachycardia compared with casualties transported by the
Questioningthelong-acceptedDUSTOFFmodel,Mabry
either PEDRO or DUSTOFF. Overall crude mortality was
et al.25 demonstrated in a recent study that casualty mortality
equivalent for MERTand PEDRO (4.2% and 4.6%) but lower
wassignificantlylowerwhenevacuationwasperformedbyUS
forDUSTOFF(0.9%).Thiswasattributed,inlargepart,tothe
Army National Guard DUSTOFF unit flight paramedics com-
finding that DUSTOFF primarily was tasked to transport less
pared with the standard military air ambulance unit’s staff by
severely injured casualties. When mortality was compared be-
EMT-Bs. This study examined 671 casualties with an Injury tweenMERTandPEDROinfourISSgroupings(G10,10Y19,
Severity Score (ISS) of greater than 15 retrieved from POI by 20Y29,and30Y75),therewasnodifferenceinthelower(G10and
the Army Guard critical care flight paramedics (CCFP) com- 10Y19)andhighest(30Y75)ISScategories.However,mortality
pared withEMT-B flight medicsor standard MEDEVAC. The
in casualties with an ISS of 20 to 29 was lower in the MERT
unadjustedmortalitywashighestincasualtiesevacuatedbythe
comparedwiththePEDROgroup(4.8%vs.16.2%;p=0.021).
standard EMT-B flight medic platform (15% vs. 8%), and af-
UsingTraumaandInjurySeverityScore(TRISS)methodology,
ter adjusting for covariates including an observed interaction
the observed mortality for MERTwas statistically lower than
betweenevacuationsystemandpatientcategory,theoddsratio
thepredictedmortalityforallISSbinsexceptforthosewithless
for the association between evacuation system and mortality
than 10 demonstrating a high rate of unexpected survivors for
was lower for those transported by CCFP compared with
MERT-transportedcasualties.PEDRO’sobservedmortalitywas
standardMEDEVAC(oddsratio,0.34;95%confidenceinterval,
as-expected with the exception of the bin ISS 20 to 29; here,
0.14Y0.88). In response to this study, US Army policy shifted
theobservedratewashigherthanpredicted.
and now supports CCFP training for all flight medics, and
The study of Apodaca et al. further demonstrates and
trainingtothatstandardhascommenced.
confirmstheeffectivenessofMERTasanenroutecarecapabil-
ityduringcombatoperations.Specifically,thestudyshowedthat
MERT Offers a Distinct Survival Advantage despite higher predicted mortality, physician-led tactical evacu-
Two recent combat trauma registry studies characterize ation achieved greater survival rates than paramedic-directed
mortalityratesforcasualtiesevacuatedfromthebattlefieldvia evacuation for battlefield casualties with life-threatening inju-
theFAMEplatforms operatingin Southern Afghanistan.21 ries.Theauthorsdiscussthelimitationsofthestudy,whichinclude
The first study by Morrison et al.21 uses both the UK itslackofvisibilityonthetacticalscenariosthatmayhaveaffected
and US combat trauma registries. The study of Morrison theseoutcomesespeciallyforPEDRO.Lastly,theauthorsdiscuss
et al. characterizes MERTas an advanced capability platform themedicalregulationprocessthatlikelyunderliesthepreferen-
and compares mortality and timelines with the conventional tialselectionofMERTforthepolytraumacasualty.Thishasbeen
platformVDUSTOFFand PEDRO, wherein the study exam- described asintelligent tasking and recognized as a critical ele-
ines 1,093 MERT patients and 628 conventional transported ment in the process of assigning the right platform to the right
patientsduringa33-monthperiodgroupedintothreeISSbins missiontomatchclinicalcapabilitywithclinicalneed.Thisisan
S134 *2013Lippincott Williams &Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JTraumaAcuteCareSurg
Volume75,Number2,Supplement2 Olsonetal.
exceptionallyuniqueconfluenceofcircumstancesandmaypro- capability. On August 8, 2011, the DHB approved and for-
videcluestoaddressingthewayforward. warded the TCCC guidelines to the assistant secretary of De-
fense for Health Affairs.30 These recommendations called for
PEDRO Performs a Unique FAME Mission
extensiveimprovementsto(1)platform,(2)providerskilllevel
ThestudyApodacaetal.isthefirsttodocumentoutcomes and oversight, (3) response time, and (4) standardization, docu-
forPEDROdemonstratingalower-than-predictedsurvivalfora
mentationprocedures,andqualityassurance.Mostprominently,
certain subset of severely injured casualties. These results,
the board recommended that DoD pursue the development of
however, may not fully account for all factors contributing to an advanced FAME capability led by an emergency or critical
survival in a combat setting because the PEDRO platform is
care physician for the transport of the most critical battlefield
traditionallyreservedforSAR/PRmissions,includingoffensive
casualtiesthatmaybesimilartoMERT.
tacticsandcomplexcasualtyextraction.Ingeneral,byvirtueof
In response to the DHB on October 28, 2011, the as-
its mission, PEDRO is more likely to be tasked to retrieve ca- sistant secretary of Defense for Health Affairs requested de-
sualties when DUSTOFF and MERT are unable to owing to
finitive evidence that would assist the DoD in meeting its
technical challenges and enemy fire. This tasking would pre- critical objective to improve FAME care in theater.31 Move-
sumablyleadtoprolongedevacuationtimes,whichcouldexplain menttowardthatgoalhasbeenheretoforehamperedbythefact
abiasforPEDRO’slowerobservedsurvivalrate.
that the DoD ‘‘lack(ed) such data as documentation compar-
Clarke and Davis26 in a recently published largely de-
ing casualty outcomes across the various FAME platforms
scriptive analysis of MEDEVAC and triage of casualties in currentlyinexistenceinAfghanistanthatsupportpilotingsuch
HelmondProvince,Afghanistan,presentcomparativeaverage
a capability.’’ Given the emergence of recent data demon-
transport time data for the three FAME platforms without of-
strating a survival advantage for severely injured casualties
fering any detail how the various times were derived. During evacuated by critical care flight paramedics25 and the MERT
a6-monthperiodendinginNovember2010,ClarkeandDavis platform21,22 for severely injured casualties, conditions seem
examined times to response, scene, critical care, and Role 3
tobeinplaceforaparadigmshifttostronglyfavorfieldingen
with critical care time ending for MERTupon arrival of the
route care POI FAME platforms with a range of scaled re-
advanced care team at POI, whereas it coincides with Role 3 suscitative capability as has been observed in Afghanistan.
timefor theother twoplatforms.Significantly,timetoRole3
What the data and experience have shown is that the three
was identical for MERTand PEDRO, while critical care time
platforms that represent different capabilities are comple-
was only approximately 12 minutes to 15 minutes faster for mentary and bring something unique to the fight based on
MERT than for PEDRO. Taken together, the results from
challenges presented in terms of weather/terrain, ongoing
Clarke and Davis might suggest that tactical considerations,
hostilities, and casualty severity of injury. The fundamental
on average, did not impede PEDRO’s time to surgical care. challenge then becomes one of recognizing and acknowledg-
However,removedfromconsiderationsofthedifferentairframe
ing these differences and working to appropriately task each
maximum air speeds and divergent response times shown by
platformtotakefulladvantageofthedifferencestoenablesafe
Clarke and Davis, these results at first glance do not allow a
missioncompletionforboththecasualty,themedicalteam,and
precise estimate of time spent on scene and best demonstrate
air crew. It is critical to note that the possibility of tasking
thatadvancedcarestartedearlierforMERT.
differentmedicalplatformsisuniquetoSouthernAfghanistan.
ItisalsoworthnotingthatPJsonboard PEDRO,unlike
Akeylogicalquestionthenbecomesoneofadiscussion
MERT, were not administering blood products and tranex- ofdegreesor providercredentialsversusplatformcapabilities
amicaciduntilDecember2010,whichcorrespondstotheend
asthenextgenerationadvancedFAMEplatformsaredesigned,
of the study period for the two aforementioned studies. This
equipped, staffed, and deployed. It is clear from our point of
factor must also be considered in the final characterization of view that FAME providers of the future should be capable of
a physician-drivenplatform being associated with higher sur-
delivering a casualty from POI to the point of initial surgical
vival rates. None of the recent studies precisely determine if
intervention and skillfully perform lifesaving interventions
improvedsurvivalfortheadvancedcareplatformswascaused and initiate advanced resuscitative measures. Simply stipulat-
byearlybloodtransfusionsonMERTor physicianactionand
ing that a doctor should be on board FAME missions could
judgmentintreatingtrauma patients.
result in the deployment of the wrong skill set of providers
who may not be trained and experienced in advanced evacu-
ation trauma care and intervention, as is the case in medical
THE WAY FORWARD
direction of the legacy DUSTOFF. It is therefore best in our
TheArmySurgeonGeneral’sDismountedComplexBlast opinion to focus on capabilities and allow the Armed Forces
InjuryTaskForceReport27andadeployedMEDEVACMedical todeterminebesthowtoachievethiscapabilitywhilefactoring
Director’s after-action report28 both noted that that the UK’s in consideration of training and sustainment for FAME pro-
MERThasbeenusedpreferentiallytoevacuatethemostseverely viders. Maintaining a force of medic/corpsmen/PJ and CCFP
injuredcasualtiesinSouthernAfghanistandespitealackofhard teamsthatcouldbeaugmentedbynursesandphysicianswhen
clinicalevidencetoanybenefit. needed might be more expedient and cost-effective to sustain
Takingnote,theCommitteeonTacticalCombatCasualty compared with fielding fully augmented teams that include
Care, which develops and recommends TCCC guidelines to allbreeds of advancedproviders,or,withclear delineationof
the Defense Health Board (DHB),29 made recommendations medicalcapabilitiesand scope ofpractice,trainingflightpara-
for improving US Department of Defense’s (DoD) FAME medics to advanced skills and facilitating ongoing real-world
*2013Lippincott Williams& Wilkins S135
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JTraumaAcuteCareSurg
Olsonetal. Volume75,Number2,Supplement2
workinthatcapacityoutsideoftheconflictmayachievethesame 7. CassidyJ.PJHistoryWebsite.Availableat:www.specialtactics.com,1999.
goal.Alternatively,perhapsitwouldrequiretheequivalentofa AccessedSeptember18,2012.
8. DepartmentoftheArmy.VietnamStudiesVMedicalSupport1965Y1970.
specializednewshocktraumaparamedicorphysician’sassistant
Washington,DC:USGovernmentPrintingOffice.1974:174Y175.
tostaffFAMEplatformsforfutureconflictsbecauseitmaybe
9. CombatSearchandRescueinSoutheastAsiaWebsite:Availableat:http://
easiertobothtrainandsustainsuchaforceoftheseprovidersin www.nationalmuseum.af.mil/factsheets/factsheet.asp?id=15122. Accessed
timesofpeace. January20,2012.
10. Brady PH. DUSTOFF Operations in Vietnam. Army Logistician; July-
CONCLUSION August1973;5:18Y23.
11. MabryRL,DeLorenzoRA.Sharpeningtheedge:paramedictrainingfor
Many potentially preventable deaths in recent conflicts flightmedics.USArmyMedDepJ.2011;92Y100.
have occurred in the prehospital phase,23 of which FAME 12. Final Report to Congress: Conduct of the Persian Gulf War. 1991.
Availableathttp://www.ndu.edu/library/epubs/cpgw.pdf.
casualty movement played a role. To address this, the FAME
13. FischerH.AmericanWarandMilitaryOperationsCasualties:Listsand
mission has evolved from rapid and efficient clearing of the
Statistics.CongressionalResearchServiceReportforCongress;2005.
battlefield to a relative extension of heretofore-fixed, facility-
14. GarnerAA.Theroleofphysicianstaffingofhelicopteremergencymedical
based resuscitative capability. Despite these recent advances, servicesinprehospitaltraumaresponse.EmergMedAustralas.2004;16:
there remains convincing evidence that an opportunity to im- 318Y323.
proveuponthisrecordexiststhroughfurtherimprovementsin 15. Hamman BL, Cue JI, Miller FB, et al. Helicopter transport of trauma
victims:doesaphysicianmakeadifference?JTrauma.1991;31:490Y494.
airframe, missiontasking,andclinical capabilities.
16. BaxtWG,MoodyP.Theimpactofaphysicianaspartoftheaeromedi-
Active involvement of physician experts in battlefield
cal prehospital team in patients with blunt trauma. JAMA. 1987;257:
medicineandforwardlifesavinginterventionandresuscitation 3246Y3250.
isfundamental to thesuccessof such aprogram. 17. Garner A, Rashford S, Lee A, Bartolacci R. Addition of physicians to
EvolutionoffutureFAMEmodelsandrequirementsmust paramedichelicopterservicesdecreasesblunttraumamortality.AustNZJ
focusonsavingliveswhilebeingsurvivableonthebattlefield. Surg.1999;69:697Y701.
18. DavisPR,RichardsAC,OllertonJE.Determiningthecompositionand
Factorsnotpreviouslydiscussedsuchastheanticipated
benefitofthepre-hospitalmedicalresponseteamintheconflictsetting.JR
numberandtypeofcasualties,theareaofcontestedterrainand ArmyMedCorps.2007;153:269Y273.
distancebetweenechelonsofcare,andairsuperiorityalsoneed 19. TaiNR,BrooksA,MidwinterM,ClasperJC,ParkerPJ.Optimalclinical
tobe carefullyconsidered. timelinesVaconsensusfromtheacademicdepartmentofmilitarysurgery
Asadesiredendstate,FAMEplatformsofthefuturewill andtrauma.JRArmyMedCorps.2011;155:253Y256.
represent a capability that will provide flexibility to the com- 20. CalderbankP,WoolleyT,MercerS,SchragerJ,KazelM,BreeS,Bowley
DM. Doctor on board? What is the optimal skill-mix in military pre-
manderandoptimizescalablestate-of-the-artforwardcarethat
hospitalcare?EmergMedJ.2011;28:882Y883.
caninitiateearlydamage-controlresuscitationwhencalledupon
21. Morrison J, Oh J, Dubose J, O’Reilly D, Russell R, Blackbourne L,
todosoforseverelyinjuredcombatants.Thelifesavingpotential Midwinter MJ, Rasmussen TE. En-route care capability from point of
of such a capability would be difficult to undervalue in the injury impacts mortality following severe wartime injury. Ann Surg.
chaotic,dynamic,andasymmetricbattlespacesofthefuture. 2012;257:330Y334.
22. Apodaca A, Olson C, Bailey J, Butler F, Eastridge B, Kuncir E. Per-
AUTHORSHIP formanceimprovementevaluationofforwardaeromedicalevacuationplat-
formsinOperationEnduringFreedom.JTraumaAcuteCareSurg.[inpress].
C.M.O.,J.B.andE.J.K.conceivedanddesignedthestudy.C.M.O.,J.B.,
23. EastridgeBJ,MabryR,SeguinP,CantrellJ,TopsT,UribeP,MallotO,
R.M., S.R., J.J.M. and E.J.K. drafted the manuscript. C.M.O., J.B., and
ZubkoT,Oetjen-GerdesL,RasmussenT,etal.DeathontheBattlefield
E.J.K.analyzedandinterpretedthedata.C.M.O.,J.B.,R.M.,S.R.,J.J.M.,
(2001Y2011):Implicationsforthefutureofcombatcasualtycare.JTrauma
andE.J.K.criticallyrevisedthemanuscript.E.J.K.providedadministra-
AcuteCareSurg.2012;73:S431YS437.
tive,technical,ormaterialsupport.E.J.K.supervisedthestudy.
24. Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK,
Mabry RL, Cain JS, Blackbourne LH, Holcomb JB. Eliminating pre-
DISCLOSURE ventabledeathonthebattlefield.ArchSurg.2011;146:1350Y1358.
AllauthorshavecompletedandsubmittedtheICMJEFormforDisclo- 25. Mabry R, Apodaca A, Penrod J, Orman JA, Gerhardt RT, Dorlac WC.
sureofPotentialConflictsofInterest.Therewerenoconflictsreported. Impact of critical careYtrained flight paramedics on casualty survival
Therewasnofundingforthisstudy.TheUnitedStatesArmyInstituteof duringhelicopterevacuationinthecurrentwarinAfghanistan.JTrauma
Surgical Research (USAISR) supported this project. All authors are AcuteCareSurg.2012;73(2Suppl1):S32YS37.
employedbytheUSDepartmentofDefense.
26. ClarkeJE,DavisPR.Medicalevacuationandtriageofcombatcasualties
inHelmandProvince,Afghanistan:October2010YApril2011.MilMed.
REFERENCES 2012:177:1261Y1266.
1. LamDM.Medicalevacuation,historyanddevelopmentVthefutureinthe 27. Caravalho J. Dismounted Complex Blast Injury - Report of the Army
multinationalenvironment.ResTechnolOrgan.2001;19:1Y7. DismountedComplexBlastInjuryTaskForce.June18,2011.Availableat:
2. GreenB.Challengesofaeromedicalevacuationinthepost-cold-warera. http://www.armymedicine.army.mil/reports/DCBI%20Task%20Force%20
AerospacePowerJ.2001;15:14Y26. Report%20(Redacted%20Final).pdf.44Y47.
3. Dorland P, Nanney J. DUSTOFF: Army Aeromedical Evacuation in 28. Mabry R. MEDEVAC Medical Director’s After Action Report. APO, AE
Vietnam.WashingtonDC:DepartmentoftheArmy;1982. 09354:UnitedStatesCentralCommand.JointTraumaTheaterSystem;2011.
4. Neel, SH. Medical considerations in helicopter evacuation. U S Armed 29. ButlerFK,GiebnerSD,McSwainNandPonsP,eds.PrehospitalTrauma
ForcesMedJ.1954;5:220Y227. LifeSupportManual:MilitaryVersion.7thed.St.Louis,MO:Mosby;2010.
5. GinnVN.TheHistoryoftheUnitedStatesArmyMedicalServiceCorps. 30. DickeyN,JenkinsD,ButlerF.TacticalEvacuationCareImprovements
Washington,DC:OfficeoftheSurgeonGeneralandCenterofMilitary WithintheDepartmentofDefense.DefenseHealthBoardMemo;2011.
HistoryUnitedStatesArmy;1997. 31. Woodson J. Response to Defense Health Board Recommendation for
6. Mock S. PEDRO News Web site. Available at: http://users.acninc.net/ TacticalEvacuationCareImprovementswithintheDepartmentofDefense.
padipaul/Pedronews/home.htm.2012.AccessedSeptember18,2012. AssistantSecretaryofDefenseforHealthAffairsMemorandum.2011.
S136 *2013Lippincott Williams &Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.