U. S. Naval Flight Surgeon Handbook: Aeromedical Evacuation*

References:

• OPNAVINST 4630.9C

• DOD 6000.11

Points of Contact:

• Global Patient Movement Requirement Center (GPMRC)
  Scott AFB, IL
  DSN: 576-6161/6162/6262 Com: (618) 256-6161/6162/6262
  

• Navy Liaison Officer
  DSN: 576-4938/4939 Com: (618) 256-4938/4939
  

• Theater Patient Movement Requirement Center (TPMRC)

  • Europe (UECOM)
    Ramstein Air Base, Kaiserslautern, Germany
    DSN: 480-8040/8041/8042/8043* Fax 480-8045*
    

  • Pacific (PACOM)
    Yokota, Japan
    DSN: 225-4700*

*Call your local DSN operator to see if applicable geographical area voice codes are required.

DOD Policy
It is DOD policy that the movement of patients of the armed forces, in both peace and war, be accomplished by airlift when airlift is available, when conditions permit and if not medically contraindicated. The policy further states that this mission will be carried out by units specifically assigned that task except when urgent medical requirements dictate otherwise. In that case, any suitable aircraft may be pressed into service.

General
Aeromedical evacuations from the field, from aboard ship and from in-garrison facilities are frequently of sufficient urgency that local aircraft assets are used in order to transfer a patient to the nearest available medical facility suitable to that patient's needs. In cases requiring higher levels of care, where immediate danger to life and limb are not urgent considerations or where considerable distances are involved, the Worldwide Aeromedical Evacuation system is used. Or, it may be that urgent cases may require removal from a remote site using local aircraft assets and a link up with the aeromedical evacuation system at some location for further transport. The Navy overseas component commander is responsible for providing aeromedical evacuation over routes solely of interest to the Navy and where the facilities of the Worldwide Aeromedical Evacuation System cannot provide this service. Thus, a burn case requiring evacuation from the middle of the Mediterranean would require use of Navy assets for transportation to some land-based U.S. facility in Sicily or Italy where the patient can then be entered into the worldwide aeromedical evacuation system.

Caution
Aeromedical evacuation is a very helpful tool, but DOD policy should not be interpreted as an absolute requirement. You may be called upon for advice or to accompany a medical evacuation requested by a non-flight surgeon medical officer. In some cases, evacuation by air may not be in the best interests of the patient or may cause harm.

One must also bear in mind that an aviator will press a mission further than he otherwise would if he believes lives are at stake, and he must so assume when an aeromedical evacuation is requested. He may, therefore, launch in bad weather or other than ideal circumstances. It is incumbent upon the flight surgeon to evaluate all factors, and if an aeromedical evacuation seems ill advised, to present that opinion to the attending physician and through the medical chain of command if necessary. Clearly, these opinions must be presented in the most diplomatic and informed of methods. When presented with carefully reasoned objectives based on patient interests and safety, most physicians will look at alternative methods of transportation. Entry into the Worldwide Aeromedical Evacuation system is a bit more tightly controlled and run by people who do this every day. That system has a series of checks which prevent such problems.

Organization of the Worldwide Aeromedical Evacuation System

Patient Evacuation System (2 components)

1. Medical Regulation (DOD)
   
   The Armed Services Medical Regulating Office (ASMRO) is a tri-service organization which processes requests from medical facilities for evacuation of individuals to facilities able to provide higher levels of care, and then arranges movement to those facilities after having balanced requirements with current capabilities. This office handles cases from overseas and within CONUS during war and peace. Regulation of patients to be transported within the overseas area is not an ASMRO function, but is rather the mission of the Unified Commander of that theater of operations who has a Joint Medical Regulating Office (JMRO) which arranges for movement. There are two JMROs, one located at Frankfurt, Germany for the European theater, and one at Ft. Smith, Hawaii covering the Pacific theater of operations.
   

2. Patient Movement
   
   This is the charter of the U.S. Air Force Military Airlift Command (MAC), 375th Aeromedical Airlift Wing. The 375th has four Aeromedical Evacuation Squadrons (AESs):

   • 57th AES, Scott AFB, IL - Largely administrative and scheduling.
     

   • 1st AES, Pope AFB, NC - The tactical evac squadron in combat situations.
     

   • 9th AES, Yokota AFB, Japan.
     

   • 2nd AES, Rhein-Main AFB, Germany.

   There are Dets of AESs as well at various turn around points and receiving facilities in the U.S. and the Pacific which provide support.

How it Works
The flight surgeon elects to medevac a patient. The nearest U.S. medical facility does not have the capability to handle the case but does have a large airport available. The flight surgeon prepares the patient for transport while the staging medical facility contacts the ASMRO (JMRO in European and Pacific theaters) with the request for movement of the patient. ASMRO (or JMRO) matches the patients requirements with the capabilities of higher level facilities for that day and then contacts the cognizant AES for movement to the final destination. Each case is regulated individually except during wartime, when large numbers of casualties may dictate regulation and transport on the basis of injury categories such as neurology injury, orthopedics, burn or other.

Airframes in Use:

• C-130 used by 1st AES primarily in the tactical role. 74 litters, 94 ambulatory.
  

• C-9A Nightingale (specific configuration). 30 litters (40 wartime) 40 ambulatory.
  

• C-141 (multi-purpose configuration). 103 litters, 168 ambulatory.

Medical Crews on Board:

• 2flight nurses.
  

• 3 aeromedical evacuation technicians.
  

• May be augmented as required.

No medical officer is aboard. The medical crew relies on the orders and diagnosis of the originating medical officer.

Patient classification (based on condition and ability to egress in an emergency)

Class 1 (Psychiatric)

• 1A - Severe psychiatric

  • a) litter
    b) hospital attire
    c) sedated
    d) restrained

• 1B - Intermediate psychiatric

  • a) litter
    b) sedated
    c) restraints available

• 1C - Moderate psychiatric

  • a) in uniform
    b) ambulatory

Class 2 (Litter)

• 2A - Immobile

  • a) litter
    b) hospital attire
    c) cannot egress

• 2B - Mobile

  • a) litter
    b) hospital attire
    c) can egress

Class 3 (Ambulatory)

• 3A - Non psych, non substance abuse going for treatment.
  

• 3B - Recovered patients returning home.
  

• 3C - Drug/substance abuse patients going for treatment

Class 4 (Infants)

• 4A - Infant/child under 3 in bassinett/car seat
  

• 4B - Recovered infant/child requiring seat
  

• 4C - Infant in incubator
  

• 4D - Under 3 on a litter
  

• 4E - Outpatient under 3

Class 5 (Outpatients)

• 5A - Ambulatory, non psych/substance abuse going for treatment.
  

• 5B - Ambulatory, psych/substance abuse going for treatment.
  

• 5C - Psychiatric outpatient going for treatment/evaluations.
  

• 5D - On litter for comfort/safety going for treatment.
  

• 5E - Returning on litter for comfort/safety.
  

• 5F - All other returning outpatients.

Class 6 (Attendants)

• 6A - Medical attendant
  

• 6B - Non-medical attendant

Movement Precedence:

1. Urgent - move immediately

Indication - to save life/limb/eyesight or prevent complications of serious illness.

Requires - Doctor to doctor referral.

*Validation by surgeon at Wing or designated overseas flight surgeon.

2. Priority - move within 24 hrs

Requires - Doctor to doctor referral.

*Validation as with Urgent.

3. Routine - move within 72 hrs

Routine flight.

GPMRC locates a bed for the patient.

4. Special - Inflight care exceeds usual capabilities

Requires special equipment/teams/expertise/limit stops/RON.

Your Responsibilities for Patient Preparation:

1. DD form 602 - (Patient evacuation tag) Legible, with primary and secondary diagnoses, orders and treatments.
   

2. Narrative summary.
   

3. Patient x-rays, records.
   

4. Medications: CONUS Travel - 3 day supply, Overseas Travel - 5 day supply.
   

5. Special Diets.
   

6. IV fluids, supplies, etc.

Special considerations:

1. Physicians

• Originating M.D. is responsible for care until patient reaches destination hospital.
  

• Medical crew may request flight surgeon evaluation.
  

• Death in flight.
  

• Do not resuscitate orders (DNR).

2. Patient

• Cardiac --10 days post MI, 5 days complication free.
  

• Anemia -- Hb/Hct8.5/30 -- May need continuous 0_2.
  

• Chest tubes -- HeimlichValve --XR to assure lung expansion.
  

• Infectious Disease -- Usually not accepted -- Special precautions -- Isolation is possible.
  

• Immobilized Jaw --Aspiration protection --Quick release mechanism (Rubber retaining bandswith scissors attached to the patient).
  

• Tracheotomy -- Change 24-48 hrs prior to flight.
  

• C-SpineFracture -- Stryker frame -- Collins traction.
  

• Pregnancy -- OB records. Medical officer with labor patient or if on Ritodrine.
  

• TB -- New: on litter with mask. Over 2 wks: chemotherapy no precautions.
  

• Casts -- Dry 48- 72 hrs. Bi-Valve all casts.
  

• Post-op -- 5 days post major surgery, and must be stable.

United States Naval Flight Surgeon Handbook: 2nd Edition 1998

The Society of U.S. Naval Flight Surgeons

*From the United States Naval Flight Surgeon Handbook: 2nd Edition, 1998, 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