What was the experience of aeromedical evacuation (AE) for the USAF in recent conflict zones like Afghanistan and Iraq, and how has this changed the way patient movement and care are handled today?

The beginning of the Iraq and Afghanistan conflicts saw significant doctrinal changes to the USAF ground and aeromedical evacuation (AE) forces. Ground medical evolved from our large, forward medical treatment facilities to smaller, modularized capabilities. The Expeditionary Medical System (EMEDS) builds capability with 25 to 50 beds at a time, allowing placement of capability where it is required for casualties. A decreased ground medical footprint depended on a robust and responsive AE system to support it. Fewer beds in the combat theater meant more frequent AE missions to ensure beds were available for casualties. A hub-and-spoke method of serving the forward locations and consolidating casualties at strategic hubs for movement out of the theater for continued care was implemented.

At the start of the conflicts, the air force deployed Critical Care Air Transport Teams (CCATTs) to complement our AE forces. AE forces provided high acuity medical-surgical care to approximately 80 per cent of our casualties and the CCATT provided critical stabilization care to approximately 20 per cent of our casualties. Both capabilities ensured a 98 per cent survival rate of patients moved in the USAF AE system. The AF also modularized our patient staging capability, matching our ground capability at our AE hubs, thereby maintaining our patient flow with our aircraft flow, both intra-theater and inter-theater. These conflicts also saw the advent of universal qualification of our AE crew members, meaning they were qualified to fly on any mobility aircraft, and the use of designated aircraft for AE missions. Aircraft were able to come into a location carrying cargo and leave the same location carrying patients.

Air Mobility Command’s principal aircraft for AE are the C-17 Globemaster III and C-130 Hercules. How are these two very different aircraft utilized in providing and supporting medical care inflight?

The C-130 is a tactical airlifter capable of both cargo and aeromedical evacuation. It has a capacity of 50 litter patients using equipment stored on the aircraft. This allows for rapid configuration and engine running on-loads and off-loads in a high threat environment. It can take off and land on virtually any semi-improved surface, drop cargo and load patients. It is primarily used for shorter missions from a high threat to lower threat, from forward role Category II medical capabilities (surgical, with limited holding capability) to more extensive role Category III (Theater Hospitalization/Combat Support Hospital).

The C-130 is a tactical airlifter capable of both cargo and aeromedical evacuation

The C-17 aircraft is a strategic airlifter capable of flying large, oversized cargo, large loads of cargo or passengers and AE. It has unlimited range as it is capable of air refueling. It can also land on semi-improved airfields. The lighting and temperature control inside the fuselage is greatly improved over the C-130, which makes it more conducive to longer strategic missions. It is primarily used for our inter-theater missions consisting of long legs between continents.

What personnel does a Critical Care Air Transport Team (CCATT) comprise of and what systems/medical equipment do they use to support their role?

The CCATT is a three-person team. A medical intensivist physician consisting of one of the disciplines of critical care, anesthesia, emergency room, trauma, cardiology and pulmonary critical care; a critical care or emergency room nurse; and a respiratory therapist. CCATTs are trained as a team at the USAF School of Aerospace Medicine. When not deployed in support of an operation, they work in our medical treatment facilities.

How does a critical care flight differ from a regular aeromedical evacuation? 

All AE missions have the same basic capability. An AE crew consists of two flight nurses and three AE technicians and if critical care patients are added, a CCATT is added to the AE crew. Our equipment for both the AE crew and the CCATT is standardized across our forces. Critical care patients may require different parameters, for instance a cabin altitude restriction, or additional oxygen support.

In what circumstances are sister service, contracted, and international partner aircraft used to supplement Air Mobility Command’s (AMC) own resources?

In the contingency combat environment, US services can and do move casualties from the point of injury to where the AE system can retrieve them. International partners do the same depending on the agreements in place for specific conflicts. Contract aircraft are usually smaller aircraft, capable of moving one or two patients at a time. The USAF uses these commonly between our Continental US facilities. Additionally, AMC is developing a program to utilize trained nursing personnel to augment the clinical capabilities of our AE crews. These medical attendant teams would carry out clinical care tasks under the direction of the AE crew, thereby expanding the number of patients that a traditional, five-person AE crew could care for. AMC is building additional resources utilizing non-traditional mechanisms.

AE forces can become involved in humanitarian assistance and disaster response sorties. How do these differ from regular military operations in the way they are handled?

The USAF AE system can be employed for humanitarian assistance or disaster relief. Our command and control, equipment and personnel packages all remain the same as for a combat response. The patients can present very different clinical diagnosis. Instead of combat injuries, they can present with chronic medical conditions, which frequently have gone untreated for a period of time due to the disaster. For instance, medication for blood pressure control, diabetic control and dialysis may have been missed. The age of the population can be very old or very young as opposed to the 20 to 40-year-olds of a combat force.

What has been the longest/most challenging AE flight made by an Air Mobility Command aircraft in recent years?

In August 2019, AMC AE crews successfully transported a severely injured 33-year-old Army soldier with multiple blast injuries on a remarkable 8,000-mile (12,875-km) non-stop mission from Bagram Air Base, Afghanistan, direct to the Brooke Army Medical Center in San Antonio, Texas. Multiple elements of CCAT were executed to keep this soldier alive during transport.

With thanks to: Captain Christopher J Herbert, USAF, Chief, AMC Public Affairs Strategy & Plans; Lou J Burton, Chief, Media Operations Office of the US Air Force Surgeon General.

REACH 797 – a four-day, 8,000-mile mission to save one injured soldier in Afghanistan

Over four days in the summer of 2019, three US Air Force (USAF) aircraft, 18 medical specialists, more than 24,000 gallons of fuel and 100 liters of blood were committed across an 8,000-mile journey toward a single goal – saving the life of one soldier

In mid-August 2019, the USAF Air Mobility Command’s 618th Air Operations Center (AOC) was notified of an injured soldier in need of urgent AE out of Bagram Air Base (AB), Afghanistan. Immediately, AOC airmen started to build a mission – REACH 797 – to help save one soldier whose survival was in question after being critically wounded in a blast.

Within the first hour of the soldier’s arrival at the Craig Joint Theater Hospital (CJTH) at Bagram AB, medical teams administered multiple blood transfusions and a lead surgeon determined the soldier was in need of a special team from Brooke Army Medical Center in San Antonio, Texas.

To form this team, the 455th Expeditionary Medical Group worked with the Enroute Patient Staging System (ERPSS). This flight is a specialized section in the hospital with personnel who are experts in patient movement to coordinate transport out of the area to more specialized care.

Their quick work led to the patient being taken to a higher echelon of care in under 48 hours

During those critical days following the injury, the surgical services team at Bagram AB performed multiple life-saving and stabilizing surgeries. Additionally, a walking blood bank was initiated, and more than 100 soldiers lined up to donate within 15 minutes of the call to ensure a sufficient supply of blood.

“Their quick work led to the patient being taken to a higher echelon of care in under 48 hours,” Maj Lisa Haik, 455th ERPSS flight commander said. “Overall, the actions of all involved represent just a fraction of what the CJTH can provide to our warriors.”

Twenty-four hours later, after being diverted from another mission, a Dover Air Force Base (AFB), Delaware, C-17 Globemaster III and its crew arrived at Bagram AB and immediately went into crew rest in preparation for a non-stop, 8,000-mile flight to San Antonio.

“We had to load up a very complex flight plan into the software on the aircraft,” Major Dan Kudlacz, REACH 797 C-17 pilot and aircraft commander from Dover AFB’s 436th Airlift Wing said. “Couple that with the fact that we were flying into a combat zone, carrying 18 additional medical crew members, and transporting a critical patient whose injuries require a cabin-altitude restriction. You can begin to see that there was a lot to manage from alert to lift-off.”

The next day, the soldier was evacuated out of Afghanistan on the C-17 for the long journey home and was treated by AE and CCATT airmen from the 10th Expeditionary Aeromedical Evacuation Flight, alongside an Extracorporeal Membrane Oxygenation team from the 59th Medical Wing.

“There were so many moving parts to this mission that we knew we had to get every aspect 100 per cent correct the first time,” Kudlacz said. “Should one thing have fallen out of line during the flight, it could have … impacted this soldier’s life, which is something that weighed heavily on all of us when we received notification of this mission.”

Just hours into the flight from Bagram AB, a KC-135 Stratotanker crew out of MacDill AFB, Florida, was preparing for a routine mission from the tarmac at RAF Mildenhall, UK, when they got the call to rendezvous with the 436th Airlift Wing C-17 and offload more than 24,000 gallons of fuel to keep life-saving REACH 797 airborne during its non-stop AE journey from Afghanistan to Texas.

As the topped-off C-17 pulled away from the KC-135 in the skies over Europe, a second MacDill AFB tanker crew, near Bangor, Maine, was diverted to complete the air bridge to Texas. Although refueling during an AE flight is uncommon due to the turbulence it can cause, it was necessary to ensure the soldier reached specialized care in the US as quickly
as possible.

“This mission involved a tremendous amount of teamwork; between the skill of the aircrews operating under exhausting conditions, to our AOC planners who determined aircraft and aircrew availability, provided mission support and tailored specialized AE care enroute and the medical professionals who provided unrivalled critical care,” Brigadier General Jimmy Canlas, 618th AOC Commander said. “With a soldier’s life on the line, these airmen worked 24/7, across multiple time zones, to pull together all the pieces and ensure this soldier made it home.”

Following the non-stop, 20-hour journey, the injured soldier reached Kelly Field, Texas. From there, he was transported to Brooke Army Medical Center to continue receiving life-saving care – and reunite with his family.