Seabee Operational Medical and
Dental Guide: Aeromedical Evacuation*
Introduction
Air transportation of sick and injured patients is commonly employed in
military and civilian medical care systems. Civilian "life-flight"
operations have contributed greatly to improving survivability of
serious injury and military evacuations have done no less in combat
operations. In peacetime, military aeromedical evacuation other than
scheduled patient movement flights to other facilities is rarely, if
ever, justified. Yet we have seen them requested for reasons as poor as
that of not trusting the ambulance to make the trip for mechanical
reasons. The dangers of flight to the crew and the patient as well as
the enormous cost (several thousand dollars an hour for an operational
helicopter) are simply not justified. A thorough knowledge of
aeromedical evacuation is essential for flight surgeons, less so for the
Seabee medical officer. Integrating aeromedical expertise with critical
care medicine makes this area challenging for the practicing flight
surgeon, who should be consulted if at all possible before the decision
is made for evacuation. While this chapter was originally written
specifically for flight surgeons, it is presented here almost unchanged
so that the reader may have an appreciation for the difficulties and
dangers inherent in aeromedical evacuation. Considerations beyond normal
medical factors are required to ensure optimal patient outcome. The
naval flight surgeon may find that these factors are especially
difficult to evaluate or predict. Factors such as the tactical
situation, aircraft availability, shore facility capability, weather
conditions, and diplomatic considerations must be included in
aeromedical evacuation planning. Theatre evacuation is the
responsibility of the operating forces. For example, if serving in an
area with the Marine Corps, they take advantage of "lifts of
opportunity". The Army has dedicated aircraft assets for evacuation from
the field. Beyond that, the Air Force has the responsibility for
worldwide aeromedical evacuation. Air Force policy has been radically
changed in the last few years, with the concept of Joint Health Service
Support, or JHSS. Formerly, all patients had to be stabilized and free
of any complications before being accepted. Now, critical care in the
air is considered a part of the new JHSS.
Historical Background
The use of aeromedical evacuation dates from World War I. In 1915, twelve
casualties were flown in unmodified service type aircraft from the battle area
during the retreat from Serbia. The French instituted the first airplane
ambulance service organization with six airplanes that could carry three litter
patients each. More than 1200 patients were transported from the Atlas mountain
area of Morocco during the Riffian War. In 1919, the British Royal Air Force
first transported casualties during the war against the Mad Mullah in
Somaliland. Stretchers were placed inside the fuselage of a DH-9 aircraft. In
1923, some 359 patients were transported in Kurdistan. In the United States,
Captain George Gosman, MC, U.S. Army, had constructed an ambulance airplane near
Pensacola, Florida in 1910. Requests for additional developmental funds were
denied by the War Department. In 1918, at Gerstner Field, Louisiana, Major
Nelson E. Driver, MC, U.S. Army and Captain William Ocker of the American Air
Service modified the rear cockpit of a JN-4 aircraft to allow litter transport.
During the next several years, ambulance aircraft were used by the U.S. Army on
an emergency basis only, despite repeated urging by Army Medical Department
officers for the routine use of transport airplanes for evacuating casualties in
the event of war. Large scale aeromedical evacuation first occured during the
Spanish Civil War (1936-1938)) by the Germans. The sick and wounded of the
Condor Legion were transported from Spain to Germany in JU-52 airplanes. Each
aircraft was configured to carry ten litter cases and from two to eight
ambulatory cases. The route involved flying over the Mediterranean to Northern
Italy, then crossing the Alps at altitudes of up to 18,000 msl. The distance
traveled varied between 1350 to 1600 miles with an elapsed air time of about ten
hours. Oxygen was available and used while crossing the Alps. The extreme cold
at altitude was a major difficulty because the airplanes did not have heating
systems. With the onset of World War II, most warring nations developed
organized systems for aeromedical evacuation. The U.S. Army Air Corps formed
medical air evacuation squadrons and established a school in 1942. Patients were
transported by troop carrier aircraft within the various overseas theaters.
Patients were returned to CONUS by the Air Transport Command. By the end of
hostilities, the Army Air Corps had transported over 1.25 million patients. The
Korean Conflict of 1950-1953 saw the introduction of helicopters. They became
the primary medical evacuation aircraft for the movement of casualties from the
battlefield to the initial medical treatment facility. Helicopters also were
used to transport patients between ships. By 23 February 1954, the U.S. Air
Force Military Air Transport Service had transported over two million patients.
The Vietnam Conflict from 1965 to 1973 saw a much fuller exploitation of the
helicopter for aeromedical evacuation. Combat search and rescue helicopters
rescued aviators who were shot down. Helicopters in support of U.S. Marines and
Army forces picked up the wounded soon after injury, and quickly transported
them to definitive treatment facilities. Helicopter aeromedical evacuation was
considered a significant factor in the decreased mortality from wounds noted in
that conflict. During World War II, about four percent of the casualties
reaching medical treatment facilities died. During the Korean Conflict, this was
reduced to two percent. The Vietnam conflict demonstrated fatality rates of one
percent for casualties arriving at medical treatment facilities.
Physiological Factors Affecting Air Transportation
Any decision to evacuate a patient by air constitutes a major value
judgement and should be made only after a thorough assessment of the medical
benefits for the patient are compared to the hazards which might be associated
with an evacuation flight. Prerequisites to this decision-making process are an
in-depth understanding of the significant and unique risks imposed on patients
during transport by aircraft. The flight surgeon must maximize patient outcome
while minimizing patient risk. There are no absolute medical contraindications
to aeromedical evacuation. Much can be done by the flight surgeon to achieve a
medically successful flight by preparation of the patient to better withstand
the stresses and risk associated with flight or by manipulation of the patient's
environment during the evacuation. These may include recommendation of flight
level in an unpressurized aircraft or a specific pressurization profile in a
pressurized aircraft in the case of dysbarism. Resuscitation and stabilization
of the patient prior to evacuation cannot be overemphasized IF the situation
permits. These principles more than any other influence the final therapeutic
outcome. On occasion, it may be prudent to delay evacuation in order to
stabilize the patient. The space limitations, light, noise or other en route
environmental conditions make routine monitoring and therapeutic procedures
extremely difficult. Conversely, there may be tactical situations where delay is
not feasible. There are specific risks inherent in aeromedical flight which
interact with medical status. These are related to physical properties of flight
and associated factors which include: reduced atmospheric pressure, decreased
oxygen tension, dehydration, motion sickness, fatigue and inactivity.
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Reduced Atmospheric Pressure
Although scheduled aeromedical evacuation flights are in pressurized aircraft,
transport aboard nonpressurized aircraft and helicopters may be required.
Rapid decompression may be experienced in pressurized aircraft. With the
reduction of atmospheric pressure, the gases present within the body tend to
expand in accordance with Boyle's Law. If unable to escape, this pressure may
rupture the containing walls of the cavity or impair circulation. The use of
pressurized splints and MAST trousers pose similar problems. There is a
well-documented incident in which MAST trousers were used to stabilize a
wounded patient. After the flight, the patient's feet were pulseless which
ultimately lead to bilateral lower extremity amputations. Ideally, the
patient's cardiovascular status should be stabilized before air transport -
unless precluded by battlefield conditions.
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Decreased Oxygen Tension
The decreased oxygen tension associated with reduced atmospheric pressure may
have significant adverse effects. Oxygen saturation is decreased only slightly
at cabin altitudes in pressurized aircraft and in flight below 10,000 msl in
unpressurized aircraft. However, this reduction can be critical in patients
with marginal sea level tissue oxygenation. Patients, at risk, include those
with anemia, recent acute blood loss, impaired pulmonary function, cardiac
failure, organic heart disease or sickle cell trait. Essentially, low flow O2 is practically never contraindicated.
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Dehydration
The relative humidity at altitude is reduced in both pressurized and
unpressurized aircraft. Dehydration may represent a risk to the unconscious,
marginally hydrated patient. Patients with tracheostomies or those who must
breath through their mouths may require humidified air or oxygen to prevent
drying of respiratory secretions. Corneal drying in comatose patients may be
averted by holding their eyelids closed with moistened cotton pads under eye
shields.
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Motion Sickness
There is a low incidence of motion sickness in large jet aircraft flying at
altitude. However, motion sickness is more frequently encountered in
helicopters and small aircraft operating at lower altitudes. Prior
administration of antihistamines (25 to 50 mg of meclizine, 50 mg of cyclizine
or 50 mg of dimenhydrinate) or "scopodex" (0.6 mg of scopolamine mg of
d-amphetamine) may reduce symptoms if not medically contraindicated.
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Fatigue and Inactivity
The ambulatory patient is sometimes transported aboard operational aircraft.
In troop transport aircraft, the crowded seat configuration may discourage the
patient from moving around during the flight. The enforced inactivity together
with the anxiety and apprehension associated with illness may produce more
fatigue than would be expected. Some geographical considerations dictate
aeromedical evacuation in ejection seat equipped aircraft (such as the US-3A
in the Indian Ocean). Such missions require careful estimation of risks and
benefits.
Medical Conditions Requiring Special Management
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Cardiovascular Diseases
Supplemental oxygen should be available in flight and vasodilating drugs
should be provided for those patients with symptomatic angina pectoris. Cabin
altitude should not exceed 6,000 msl. Patients in congestive failure or with a
history of any myocardial infarction within eight weeks of the acute episode
must be evaluated on a case-by-case basis prior to transportation. The
American College of Chest Physicians recommends that a cabin altitude not
exceed 2,000 ft msl without supplemental oxygen for such patients.
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Pulmonary Diseases
In patients with artificial, traumatic or spontaneous pneumothorax, movement
by air should be deferred until radiographic studies demonstrate gas
absorbtion. However, if the volume of gas remaining is small, restriction of
altitude may enhance safe movement. Chest tubes may be left in place, but the
Heimlich Valve must be applied. All flight attendants must be instructed in
the proper use and function of the Heimlich valve. Patients should not be
airlifted for 72 to 96 hours after chest tube removal and a roentgenogram
should be obtained within 24 hours of flight to document full lung expansion.
Advise the receiving facility of the importance of a repeat chest X-Ray when
the flight is completed.
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Anemia
Patients with severe anemia or recent acute blood loss should have a
hematocrit of above 30 percent prior to entering the aeromedical evacuation
system. Hematocrit should be checked within 36 hours prior to flight. Patients
with sickle cell trait pose additional risks. The use of a portable SAO2 Monitor in flight is recommended. The presence of
an acute infectious process in those patients experiencing reduced oxygen
partial pressure may precipitate a sickling crisis manifested by sicklemia,
vomiting, and left upper quadrant pain.
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Gastrointestinal Diseases
Large unreduced hernias, volvulus, intussusception, and ileus are particularly
susceptible to trapped gas phenomena. The circulation of the involved bowel
loop may be severely compromised from trapped gas expansion. Air transport of
these patients should usually be deferred until after definitive therapy and
recovery. If transport is mandatory, it can usually be accomplished safely if
altitude is restricted. It is conceivable that weakened viscus walls in
peptic, amoebic, typhoid, or tuberculous ulcers could rupture from the
pressures of gas expansion. Disruption of a surgical incision postoperatively
due to intra-abdominal gas expansion is a threat. A 10 to 14-day convalescence
period prior to aeromedical evacuation is recommended after abdominal surgery
if possible. Colostomy patients evacuated by air require an extra supply of
colostomy bags and dressings.
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Orthopedic Patients
Casts should be clearly marked with the date of application and the nature of
the fracture or surgical procedure performed. All casts, including the
underlying web rolling and padding, should be bivalved to allow for soft
tissue swelling at altitude. The air splints commonly used for initial
stabilization pose a similar potential problem and must be constantly
monitored during flight and adjusted to prevent any tourniquet effect. It is
preferable to use wire-ladder splints, wood splints or plaster splints to
stablilize fractures and servere sprains. Traction devices using swinging
weights are unsuitable for use in flight from the standpoint of efficiency and
safety. The Hare traction device is an extremely effective tension devise for
providing traction to the extremities. Paraplegic patients are generally moved
on a Stryker frame to facilitate care and comfort during the flight. It is
important that the entire frame accompany the patient since parts from various
frames may not be interchangeable.
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Eye Injuries and Diseases
Perforating damage to the globe is a common cause of aeromedical evacuation.
Because the eye is normally liquid filled, it is not affected by barometric
pressure changes. After surgery or trauma, air may be introduced. In such
instances, a lower cabin altitude must be maintained in order to prevent
barotrauma reopening the wound or separating the surgical incision. In
patients having choroidal or retinal disease or injury, oxygen should be
administered at cabin altitudes above 4,000 msl.
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Ear, Nose, Throat Disease
The presence of an incidental upper respiratory infection may complicate
aeromedical evacuations for other injuries or illnesses. Administration of
decongestants may be considered to prevent barotrauma. Aeromedical evacuation
of patients with facial fractures may be required. The facial sinuses may have
been damaged and contain mixtures of air and fluid. The ostia may be plugged.
The patients may be unable to Valsalva due to medication, or impairment of
dexterity or cognition. Such cases should be carefully evaluated.
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Skull Fractures
Any patient with a skull fracture which extends into a paranasal sinus,
external ear canal or middle ear must be carefully evaluated. The possibility
of air having entered the cranial cavity must be excluded. If air has entered
the cranial cavity, aeromedical evacuation must be accomplished at cabin
altitudes maintained at as near sea level as possible.
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Mandibular Fracture
Commonly, mandibular fractures are wired to stabilize the jaw. Should the
patient become airsick, he may be at risk for massive aspiration of vomitus.
If aeromedical evacuation is anticipated, the patient's upper and lower jaws
should be immobilized using elastic bands. An emergency release mechanism must
be provided which can be activated by either the patient or the attendant.
Unless the patient is Class IA or IB (psychiatric litter patients requiring
restraints or tranquilizers) or under guard, he should have a pair of scissors
attached to his person.
Evacuation Precedence and Classes
Patient precedence for aeromedical evacuation is classified into three groupings
by OPNAVINST 4630.9C: urgent, priority, and routine.
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Urgent
Describes an emergency case which must be moved immediately in order to save
life, limb, eyesight or prevent complication of serious illness. A special
mission will be required to pick up the patient and deliver him to his
destination medical facility. An aircraft already in the air may be diverted
or an alert aircraft may be launched. By definition, psychiatric cases or
terminal cases with very short life expectancy are not considered urgent.
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Priority
For patients requiring prompt medical care not available locally. Such
patients should be picked up within 24 hours and delivered with the least
possible delay.
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Routine
For patients who should be picked up within 72 hours and moved on routine
scheduled flights. Several classes of patients are detailed in OPNAVINST
4630.9C. These are summarized as follows:
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Class 1- Neuropsychiatric Patients
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Class 1A. Severe psychiatric
litter patients who require restraints, sedation, and close supervision at
all times.
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Class 1B. Intermediate severity
psychiatric litter patients who are sedated but not restrained. Restraint
equipment should be available if needed because patients may react badly
to air travel or commit acts likely to endanger themselves or the aircraft
safety.
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Class 1C. Psychiatric walking
patients of moderate severity, who are cooperative and proved reliable
under observation.
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Class 2. Litter patients other than psychiatric
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Class 3. Walking patients (other than psychiatric) who require medical
treatment, care, assistance, or observation en route.
Evacuation Decision Consideration
The medical officer must account for many factors when making decisions
regarding the evacuation of patients. The flight surgeon may be called on to
supervise the patient's care during initial aeromedical transportation to the
carrier. It is important for the flight surgeon to be actively involved in
patient care as early as possible. Requests for aeromedical consultation may be
received by message, by telephone or radio from shore facilities, or from troops
in the field or from other ships. Flight surgeons are uniquely qualified to
consider the many factors involved which include:
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Diagnosis and prognosis of the patient.
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Facilities available ashore.
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Transportation modalities ashore.
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Holding and transfer facilities available ashore.
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Diplomatic and legal aspects.
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Patient and crew safety in aeromedical evacuation.
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Stretcher capabilities.
Diagnosis and Prognosis of the Patient A patient who is going to die without neurosurgical intervention or one who
will lose a limb without a vascular graft represent one extreme. The other is
the patient with an undiagnosed illness which might reflect a normal variation
(or might be fatal if not treated early.) Of paramount concern is the urgency
of treatment, the uncertainty of diagnosis, and an estimate of the effects of
treatment delay or deferral on the patient's prognosis.
Facilities Available Ashore Flight surgeons and senior medical officers should be aware of hospital
capabilities in their cruising area. The Air Operations Officer can supply
lists with nearby airfields and their facilities. The Port Directory usually
has a description of nearby hospitals. A list of U.S. military hospitals and
facilities is generally available in foreign areas. Consular and embassy
staffs can provide great assistance in determining local medical facilities
and the diplomatic and administrative procedures required for admission of
patients. Previous cruise reports also may be useful. Discussions with force
medical officers may be informative. Planning for such eventualities should be
included in preparations for deployments. Certain geographic locations and
tactical scenarios may dictate prolonged stabilization and treatment aboard
the carrier rather than transfer to inadequate facilities ashore
Transportation Modalities Ashore Helicopter transfer to the selected hospital is the preferred method. Use of
suitable ground or small ship alternatives may be required. Geographical
considerations may require transportation via Carrier Onboard Delivery (COD)
aircraft or air wing assets to a suitable airfield, with transfer to a
hospital or awaiting Military Aircraft Command (MAC) aeromedical aircraft.
Holding and Transfer Facilities Patients may have to be held pending transfer to other means of
transportation. Facilities for such transfer must be appropriate. This should
be included in the aeromedical evacuation plan.
Diplomatic and Legal Factors Diplomatic considerations must be entertained for the nation in which the
hospital and any en route airfield are located. Diplomatic clearance or other
administrative procedures may require delays that the exceed time available.
Patient and Crew Safety in Aeromedical Evacuation Safety of the crew of a helicopter or COD aircraft is a further consideration.
It is far better to keep a questionable case on board than to subject the
patient, crew, and aircraft to a flight made unsafe by reason of inclement
weather, crew fatigue, enemy action, or mechanical unreliability. Aircrews
often accept excess risk for medical evacuation missions. The flight surgeon
must be aware of this when making evacuation decisions. He must consider the
many facets of the problems mentioned here plus factors which will become
apparent only on the scene and at the time. Each facet exerts its own
influence as a determinant in the decision making process. Many aircraft and
crews have been lost because they were launched on missions that proper
prelaunch medical evaluation would have cancelled. The flight surgeon and
senior medical officer must be integrated into the ship's command structure to
ensure early notification and planning for medical evacuation eventualities.
Stretcher Capabilities Three types of stretchers may be available on ships for medical use: Stokes
(rigid), Neil-Robertson (semirigid), and the field (pole litter). The Stokes
Stretcher. The Stokes stretcher is a wire basket with a frame. It is contoured
to give support to the occupant and to keep the frame between the patient and
possible impacting objects. It has a wooden slat frame in the torso section,
lines attached to the head and foot for lifting, and straps at the torso and
midleg to restrain the patient. It is light, strong and usually readily
available. Once a patient is properly placed on a Stokes litter, he can be
transported directly to sickbay for care, carried to the flight deck, loaded
aboard a helicopter and flown to more definitive medical treatment facilities,
all without transferring him from the original stretcher. The Neil-Robertson
Stretcher. The Neil-Robertson semirigid stretcher is specifically designed to
allow the patient to be packaged in the smallest possible volume. Thus he may
be moved through restricted openings in the shipboard environment. Greater
care must be utilized in transporting patients in the semirigid stretcher
aboard ships because the stretcher offers minimal protection from aggravating
existing or causing additional injuries during transport. The advantage of
this stretcher is that it can be used in spaces where the Stokes rigid
stretcher cannot be employed. It can also be lifted vertically in the escape
trunk. It is the stretcher of choice in patient evacuation from or through
confined spaces and restricted passages. The Field Stretcher. The field
stretcher or pole litter is carried aboard the ship primarily for use by the
Marines and by landing parties. It occupies less floor space than the Stokes
rigid litter and gives greater protection than a Neil-Robertson semirigid
litter. However, it is inadequate for patient transportation from confined
spaces. It is the required stretcher for MAC flights. It is the usual
stretcher for helicopter medical evacuation flights. A Stokes litter is
preferred if a patient will be catapulted from the carrier because of the
additional protection from acceleration stresses. With the field stretcher, an
air mattress must be used to give comfort comparable to that of a Stokes
litter.
Aircraft Capability Considerations
The U.S. Navy and Marine Corps have no aircraft dedicated to aeromedical
evacuation due to limited aircraft and flight deck capability. Instead, tactical
aircraft must be diverted from operational assignments to perform aeromedical
missions. This can pose significant problems and requires thoughtful interaction
between the medical department, the receiving medical treatment facility, the
air operations department, and other line organizations. Aboard the aircraft
carrier, the senior flight surgeon should be intimately involved with all
aeromedical evacuation operations from beginning to end. Aboard other aviation
capable ships, the senior medical department representative or general medical
officer should remain cognizant of medical evacuations. These represent high
risk operations for the patient and other assets and demand thorough
preparation. Various military aircraft may be available for aeromedical
evacuation. Fixed wing assets may include the C-130, C-9, C-141, C-5A, C-12, and
P-3C. Helicopter assets may include the UH-1N, SH-2F, SH-3G, CH-46E, CH-53D, and
SH-60B. However, capabilities and availabilities may vary considerably. Similar
aircraft may have different capabilities due to installed equipment such as
OMEGA navigation equipment, VHF communication radios, extended range fuel tanks,
extended life rotor head bearings, etc. Such factors can mean the difference
between success and failure for aeromedical evacuation missions. Flight surgeons
must be aware of available aviation assets, their capabilities and procedures
for obtaining those assets. Aeromedical evacuation is undertaken to transport a
patient to a more capable medical treatment facility, either afloat or ashore.
Thus, patients may be transferred from destroyers and frigates to the aircraft
carrier to utilize expanded diagnostic and treatment capabilities. Similarly,
patients may be transported from the carrier to shore facilities for diagnostic
and therapeutic reasons. Normally, the flight surgeon is concerned with forward,
tactical, and certain intratheater aeromedical evacuations.
Military
Airlift Command Aeromedical Evacuation System
A cost effectiveness study was completed following World War II which showed
aeromedical evacuation was more beneficial to the patient than surface
evacuation. It also saved attendant time and resulted in better utilization of
crew members and trained medical personnel. The Secretary of Defense in 1949
directed that evacuation of sick and wounded military personnel would be
accomplished by air in both peace and war. Hospital ships and surface
transportation might be utilized if deemed necessary in unusual situations. That
policy was formalized in OPNAVINST 4630.9 series which limits aeromedical
evacuation functions to units assigned to that mission. Local aviation assets
may be used for aeromedical missions for medical urgent situations. The base
commanding officer and medical officer must determine that utilizing routine
aeromedical evacuation services is likely to endanger life, limb or cause a
serious complications resulting in permanent loss of patient function.
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Types of Aeromedical Evaluation Flights
OPNAVINST 4630.9 distinguishes various types of aeromedical evacuation flights
based in part on origin and destination. Domestic aeromedical evacuation
provides airlift for patients between points within CONUS and near offshore
installations. Intertheater evacuation provides airlifts for patients between
medical treatment facilities inside the combat zone and outside the combat
zone. Forward aeromedical flights are limited to flights for patients between
points within the battlefield and from the battlefield to the initial point of
treatment and subsequent points of treatment within the combat zone. The Navy
overseas commander is responsible for routes solely of interest to the Navy
and Marine Corps when the Air Force cannot provide the services.
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Aeromedical Evacuation Network
The Air Force Military Airlift Command (MAC) operates a world wide network of
aeromedical flights and support facilities. The global system can be divided
into three areas, each with its own command: the domestic system, the Pacific
system, and the Atlantic system. Domestic System. The domestic system supports
CONUS, Caribbean and Northeast Atlantic, centered at Scott Air Force Base,
Illinois. There are "trunk" and "feeder" lines to support the seven MAC
aeromedical units: Scott AFB, Illinois; Lowry AFB, Colorado; Travis AFB,
California; Kelly AFB, Texas; Maxwell AFB, Alabama; Andrews AFB, Maryland, and
McGuire AFB, New Jersey. Pacific System. The Pacific system operates from
Hickam AFB, Hawaii and supports the Pacific fleet area. Atlantic System. The
Atlantic system operates from Rhein-Main AFB, Germany for flights in Europe
and the Atlantic area. Staging Facilities. At selected sites along the air
evacuation routes are Aeromedical Staging Facilities. The medical facilities
provide reception, processing, ground transportation, feeding, and limited
medical care for patients entering, en route, or leaving the aeromedical
evacuation system. Similar in function, but more highly mobile are the Mobile
Aeromedical Staging Facilities for use in combat zones.
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Criteria for Aeromedical Evacuation
As much as possible, MAC will meet the following criteria in providing
aeromedical evacuation services: Again, JHSS wartime considerations will now
permit movement of critical patients. 1. Movement of patients within CONUS
shall be no later than 36 hours after arrival. 2. Patients shall be delivered
to their destination within 72 hours after entry into the domestic system. 3.
There shall be an average of not more than one overnight (RON) stop between
entry into the domestic system and delivery at the destination. 4. A RON stop
shall not exceed 36 hours. 5. Time in transit shall not exceed 18 hours prior
to an RON stop for rest and recuperation.
Humanitarian Aeromedical
Evacuation
For purposes of air transportation eligibility, DOD regulation 4515.13R divides
patients into U.S. armed forces and non-U.S. armed forces categories. U.S. armed
forces patients are by definition active duty or eligible retired members of the
armed forces, dependents of eligible active duty service members or retired
members under provision of SECNAVINST 6320.8, or U.S. citizen civilian employees
of the Department of Defense and their lawful dependents when stationed outside
CONUS. Emergency lifesaving aeromedical transportation is authorized for non-U.S.
armed forces patients satisfying the following criteria. 1. The patient's
illness or injury is an immediate threat to life. 2. The medical capabilities in
the patient's immediate geo- graphical area are not adequate for diagnosis and
treatment under generally accepted medical standards. In these cases,
transportation will be furnished only to a medical treatment facility which can
provide the necessary treatment. 3. Suitable commercial transportation is not
available. Non-U.S. armed forces patients will not be accepted for movement if
their condition is terminal or if the only reason to request military
transportation is lack of personal funds, personal or family convenience, or
medical experimentation (unless competent medical authority determines that such
experimentation will save a life).
Patient Preparation
Proper patient preparation is critical. Well thought out medical evacuation
preparations will reduce morbidity and mortality. A five minute helicopter
flight to a nearby medical facility may require limited planning and
preparations. Major planning is required for an aeromedical evacuation that
includes a long helicopter flight to meet with a MAC aeromedical evacuation
airplane at a foreign airport with further transport to a distant tertiary care
hospital. It is probably better to over plan such activities than to have
problems during the transport. Patient preparations include the following:
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Brief the Patient The patient should be briefed regarding his medical condition, medications,
emergency procedures and prognosis. He should be familiar with the aeromedical
system, routing, baggage limitations, need for personal funds, appropriate
uniform, destination hospital, and any other, information.
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Patient Medical Treatment Records The patient's medical records, narrative summary and other medical information
should be included. Prudence requires making copies of this information prior
to transfer. Sending patients with inadequate medical documentation does a
disservice to the patient and the receiving treatment facility. Do not neglect
to send X-Rays.
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Patient Personal Records The patient must carry his military identification card and official orders.
Personnel records, baggage, and other personal items may have to be gathered
and sent along with the patient.
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Medical Support Equipment,
Supplies, and Medication Sufficient medical support equipment, supplies, and medication for five days
should accompany the patient. All drugs should have the name, strength,
dosage, or prescription affixed. Extra batteries, bandages, IV fluid and
tubing, or other needed items should be included, particularly for a
complicated transfer. Reliance on other sources of medical equipment is
fraught with problems. A fly-away medical kit should be maintained by the
medical department since rapid response may be required.
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Medical Readiness for Transfer Ensure Maximal Medical Readiness for Transfer.
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Give preflight medications as
needed.
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Transfuse patients with hematocrit
less that 30 per cent. Give IV fluids when required as close to departure
time as possible, with access maintained as appropriate.
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Apply indwelling catheters in
cases requiring frequent catherization. Supply irrigation solution if
required.
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Apply clean dressings as near the
time of departure as possible, particularly for colostomies, draining
wounds, burns, and pressure sores. Ensure that adequate dressing supplies
accompany the patient.
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For patients with mandibular
fractures, immobilize upper and lower jaws with elastic bands rather than
wire, and provide an emergency release mechanism. For a patient with
immobilized jaws, ensure that a pair of scissors is attached to his person
unless he is a Class 1A or 1B patient or under guard.
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Bivalve all casts which are
applied within 24 hours of departure.
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Sedate neuropsychiatric Class 1A
or 1B patients and deliver them to the aircraft in a litter dressed in
pajamas.
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Apply restraints to all Class 1A
patients and to any Class 1B patients who are combative, suicidal, violent,
or considered doubtful.
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Medical Attendant The patient should be accompanied by appropriate medical personnel. This may
include a medical officer or corpsman. The needs of the patient must be
balanced against the operational needs of the ship or unit. The attendant must
have appropriate orders (with TANGO numbers), funding, uniforms, civilian
clothes, passports, medical equipment, medications, or other necessary items.
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Follow-up The ship's medical department should follow up the medical evacuation. The
status of the patient should be monitored throughout the transport and
thereafter. The medical department, the patient's command, and his shipmates
have an interest in him and his welfare. Requests for updates via message may
be considered at ten day intervals after transfer.
Bibliography
-
American College of Surgeons.
-
Advanced trauma life support.Chicago,
IL: American Medical Association , 1989.
-
American Heart Association. Advanced
cardiac life support. Dallas,TX: American Medical Association, 1988.
-
AMA Commission on Emergency Medical
Services. Medical aspects of transportation aboard commerical aircraft.
Journal of the American Medical Association. 1982, 247, 1007-1011.
-
Baird, R.E., McAnnch, G.W., &
Ungersma, J.A. High altitude penetrating chest trauma. Military Medicine,
1981, 191, p.337.
-
Johnson, A. A treatise on
aeromedical evacuation. Aviation, Space, and Environmental Medicine, 1977, 48,
550-554.
-
McLennan, J. & Ungersma, J.A.
Pneumothorax complicating fracture of the scapula. Journal of Bone and Joint
Surgery, 1982, 64,598-599.
-
McNeil, E.L. Airborne care of the
ill and injured. New York: Springer-Verlag, 1983.
-
Tension pneumopericadium following
penetrating chest injury. Journal of Trauma, 1987, 27, 800-808.
APPENDIX CHECKLIST FOR AEROMEDICAL EVACUATION PROCEDURES
-
Evaluate the patient and the
situation.
-
Is the patient stable enough to be
transported?
-
How soon should the patient be
transported?
-
Are medical evacuation assets
available to pick up the patient and deliver him to adequate facilities?
-
Notify the ship's captain of the
need for medical evacuation.
-
This is a recommendation, the captain may decide against evacuation for
reasons known only to himself. Ship's company and air assets will be as
supportive as possible.
-
Coordinate with accepting facility and transporting agency.
-
Provide for medical needs for evacuation.
-
Assure sufficient equipment, supplies, and medications are available for
medical evacuation (e.g., oxygen, IV fluids and tubing, splints, blankets,
helmets, cranials, flotation devices). A fly-away bag should be maintained
with common requirements, medications and equipment for delays enroute.
-
Label each medical container with name, rank or rate, SSN, generic name,
dosage rate, and date.
-
Provide clear instructions for medications, equipments, and supplies.
-
Ensure that manifest and personal identification requirements are met.
-
Provide manifest as per BUMEDINST 4650.2A DD form 601.
-
Ensure patient identification per BUMEDINST 4650.1A DD form 602.
-
Courtesy suggests a list of all patients in the flight should be sent to the
accepting facility's senior medical officer. The list should include name,
rank or rate, SSN, diagnosis, medications and special requirements.
-
Ensure that record requirements are met. Records should be enclosed in a
large, sealed manila envelope clearly labeled with name, rank or rate, SSN,
destination, and diagnosis.
-
Health record, including outpatient, inpatient with completed narrative
summary describing problems (history, physical examination, laboratory,
medications, and plan). A copy of appropriate records should be maintained
if possible.
-
Dental records.
-
Pay records, service record book, etc.
-
Passport, official orders with TANGO number, etc.
-
Prepare medevac crew.
-
Advise the pilot or HAC of the patient's condition. Make recommendations
about flight altitude, pressurization requirements, equipment requirements,
duration of expendables, handling of emergencies, etc. Request that the
pilot or HAC notify the receiving authority 5 to 10 minutes prior to
arrival. Inform the pilot or HAC to expect updates on the medical condition
periodically during the flight.
-
Brief aircrewman on the status of the patient and the need to make regular
reports to the pilot or HAC on the patient's status. He also should be made
aware of the patient's special needs.
-
Prepare the medical attendant. He must know the diagnosis, medications and
their administration, and how to use equipment and supplies. The medical
attendant must also have appropriate clothes, ditty bag, official orders
(including TANGO number), passport, money, credit cards, etc.
-
Brief the patient.
-
Medical conditions, requirements for transfer, anticipated flight
conditions, duration of flight, destination.
-
Emergency escape procedures.
-
Special equipment utilization and function.
-
Notify the receiving medical authority before the flight departs.
-
Name, rank or rate, and SSN of patient.
-
Diagnosis, symptoms, and reason for transfer.
-
Equipment, medication, and supplies.
-
Destination and ETA.
*From the Seabee Operational Medical and
Dental Guide, as found in Operational
Medicine 2001, Health Care in Military Settings, NAVMED P-5139, May 1,
2001, Bureau of Medicine and Surgery, Department of the Navy, 2300 E Street
NW, Washington, D.C., 20372-5300 |
