August 14, 2012

Are medical evacuation efforts worrying militaries?

Defence IQ
Contributor: Richard de Silva
Posted: 07/26/2012 12:00:00 AM EDT | 0



With the conflict in Afghanistan winding down and the withdrawal of all major international forces rapidly approaching, commanders have realised that the window of opportunity to learn, test and analyse for tomorrow’s conflict is beginning to slide shut.

Specifically, the US military and other key players have all begun a concerted research drive for information, particularly when it comes to ensuring the survivability of troops on the frontline.

The biggest area of concern appears to be in the fields of battlefield healthcare and medical evacuation, which require constant improvement despite the leaps and bounds in progress over the past fifty years.

Real-time research already being carried out in Afghanistan includes MRI scanning on troops suffering mild trauma to the brain from IED incidents and the effects of high-altitude on damaged brains during medevac.

As per the culture of modern armed forces, past experiences in evacuation – both of distant history and of more recent occurrence – must undergo thorough analysis and assessment in order to improve procedures in the future.
Compiling an accurate understanding is not an option. In fact, it is now felt by many commanders that the reliability of personnel extraction and of long-term healthcare for troops have a key impact on the path of conflict.

Personnel Recovery vs Public Relations

The indelible relationship between the two types of PR is hardly news to those who know their history.

The US in particular puts so much value in personnel recovery today because reportage of POW losses and rescues has had such a resonant effect on the perception of a campaign, as well as the politics and President involved, for over 60 years.
Looking back at the recent activity in Libya, the downing of an F-15 in March 2011, caused by nothing more than an onboard technical failure, saw no crew captured or killed thanks to the urgency given to recovery operations on the insistence of senior commanders.

Had this not been the case, it could well be argued that the entire operation may have failed, owing to the inevitable public backlash. For certain, Barack Obama would certainly be looking far less confident of re-election.

More recently, UK Special Forces experienced a rare mission failure when attempting to rescue British and Italian hostages from a Nigerian branch of Al-Qaeda. The result was not only a tragic loss of life, but also added pressure on ministers and led to a dispute between the UK and Italian governments over blame and procedure.
So there is indeed a strategic reason for this upswing in recovery and in combat healthcare. As John Frisbee of AirForce Magazine once said of the military intervention in the 1975 seizing of the SS Mayaguez, “it was important to counter a growing feeling among US allies and adversaries that this country was a ‘helpless giant’, an unreliable ally lacking resolve.”

Time has not changed this requirement, but what has changed is the attention from senior leaders to the immediate need for recovery operations to continue to receive analysis and investment, given the general success of PR efforts across the board.

Improving Joint PR Operations

Paul Miller, Director of the Personnel Recovery Education and Training Centre (PRETC), outlined the problems in planning such operations as being a “cognitive” issue.

There can frequently be a lack of understanding in the planning phase, often when operators are oversimplifying or generalising the task at hand to the rest of the team.

During execution itself, Miller believes it to be a challenge to find any time to question or analyse the operation, or indeed to theorise on the wider implications of the actions being undertaken, and yet there must be a method of focus under which this can be achieved.

“Leaders may understand the value of PR,” said Miller, “but if they only understand
it when it occurs, that’s too late.”

“Leave no one behind – we’ve all heard the phrase, but there needs to be a tactical plan ahead of time to ensure that happens.”

In that sense, Miller demonstrated the complexity of the decision and implication process, pointing to a list of considerations such as evaluating the uniqueness of other services involved in an operation – as well as coalition partners, other governments and authorities – and then fully grasping where the capabilities and responsibilities may rest.

“It goes against our human nature to not just act, but sometimes you have to pass over PR to more able partners, even if that’s hard for us to do.”

21st Century Medevac

Back in World War II, the time to transport a patient from the frontline to a hospital on home soil could take up to 90 days by land or sea. Yet it was during this conflict that helicopters first introduced a proven requirement for fast and effective medical evacuation.

Before this time, primitive air ambulances had been used to some benefit in Europe during World War I, greatly reducing the mortality rate. Even before this, in 1866, Jules Verne had written a ‘science fiction’ tale in which sailors are recued by hot air balloon – a scenario that came true a mere four years later during the Siege of Paris.

Today, the United States Air Force has 32 Aeromedical Evacuation (AE) squadrons in operation, working alongside other valued medical units including physicians, reserves, and CCATT (Critical Care Air Transport Team) members.

As each AE crew complement requires two flight nurses, training has been honed to between 11-18 weeks to bring a registered nurse to the standard for flight nurse. This universal qualification demands that the nurse trains on three altogether different types of aircraft: KC-135; C-130; and C-17. As such, the individual is outfitted with the awareness of different loading systems, oxygen needs, and other variables.

While US forces had seen only a 6 per cent drop in the combat mortality rate between World War II and the 1990 Persian Gulf War (30 per cent to 24 per cent) – owing perhaps to AE long being viewed as a last resort behind the philosophy of getting the injured soldier fixed up and straight back into action – the figure for recent campaigns in Iraq, Afghanistan and Libya is under 10 per cent.

The reason behind this change is down to a number of factors, but the formation of CCATTs in 1996 has been a huge boon owing to its focus on continuously stabilizing patients during transport. These teams offer the specialities of a CC doctor, a CC nurse, and a cardiopulmonary technician, all individually trained within an 8 week programme.

Alongside the progress was the attention to joint trauma solutions, which exposed a gap in critical care within the aircraft. To address this, Tactical Critical Care Evacuation Teams (TCCETs) have also been established to provide even more advanced care, from aggressive resuscitation at the point-of-injury and throughout the evacuation process.

Today, the average timeframe for getting a wounded soldier from the battlefield to surgical care is between 20-75 minutes, while taking a downed infantryman from the combat zones of Enduring Freedom to the military hospital in Landstuhl is between 24-48 hours, and to the Continental United States (CONUS MTF), just 2-4 days. This is quite an improvement on the 8 day average at the beginning of the Afghanistan campaign, and even more so on the 45 days once suffered by those deployed to Vietnam.
Among the planned improvements paving the road forward are agreements with Australia, the UK and Canada on the mutual use of equipment and landing space, such as flying US teams into Camp Bastion.

Tailing off from joint operations is the new Instructor Exchange programme, offering medical staff from all militaries the chance to tap into a wider pool of operational lessons.

New Technology

As USAF looks to develop its medical capability at a strategic level, so to is it looking to develop the instruments on-hand.
AE teams are now benefiting from the likes of video assisted intubation, vacuum spinal immobilisation and virtual (simulator) training.
Colonel (Rtd) Jace Sotomayer, senior advisor to the Air Force Surgeon General HQ, has a firm understanding of the needs for airborne combat healthcare given his background as an aviator.

His work involves liaising with analysts, academics and manufacturers to work out the best approaches to modernising equipment at every level, from where there is an immediate hazard present to when evacuation and en-route care is required.
“Modernisation is a long and consistent road and we’re always trying to improve.
“Budget cutbacks are always noted but it is something that has to happen or you’re going to be obsolete.”

Sotomayor explained that there are two paths to improving equipment; one is the long development laboratory based approach for high-tech systems, and the other is looking at what the industry have waiting on the shelf and whether that is something the military can augment to fit its immediate needs.

Approving private sector technology off course requires testing and often, where aeromedical units require the same sensitive equipment to work in a variety of platforms, there is more difficulty in getting them to meet all operational standards.

He gave the example of a NATO-standard litter with undercarriage sensors to measure the body for vital signs:

“Looked good in the lab, company brought it forward, the work was good, however, as part of a field test, we put it onboard one of our rescue helicopters.
“The propeller blades of the helicopter caused a frequency change, so the readings were altered.

“In fact, GPS had had the same problem, radios had the same problem – these things can be overcome, you just have to work at it, but just because you have a good piece of equipment doesn’t mean it’s going to work in all places and in all cases.”
As to the emerging technologies that were proving significant, Sotomayor referred to diagnostic instruments, including a virtualisation effort called ‘FELIX’, named after the cartoon cat and his bottomless magic bag of tricks.

“Your first responder will open a bag and be able to pull out a device that will give you some form of medical treatment – a small technology, a diagnostic device, something to transmit or receive information quicker, a video transmitter that will allow you to conference with a doctor somewhere else in the world.
“Data’s no good unless we can move it, so we’re trying to link that data through a standardised data network cloud, so the data is effective not only for immediate treatment, but when the troop gets back, his data record is there.”

Medevac Worldwide

Akin to the Instructor Exchange programme, forces from many countries are finding increasing value in working with friendly nations, but in itself, this approach also presents its own share of problems.
Lieutenant Colonel Jose Peralba, the head of a medevac unit for the Spanish Air Force who was stationed recently at Bagram Airfield, spoke on the issue of interoperability.

“It’s becoming a more and more important issue as we are working in multinational environments and most of the international conflicts that the US and Europeans are involved in,” he said.
“Protocols differ quite a bit and there’s a lot of mistrust from different countries who like to take care of their own patients.

“The only way to surpass that is to have common protocols and feedback on testing.”
Peralba also has the same concerns that worry every one of his international counterparts, such as the ongoing debate over the degree of readied medical care required on the aircraft.

“If you get a severely wounded combatant, you may need to get more than just a combat medic on the forward helicopter, but we may be told we are risking sparse resources like doctors and nurses, but on the other hand, you are risking a lot of other resources on those same missions by not using them.
“So it’s a command call, and we need to ‘protocolize’ how to intervene in those cases.”

Every nation possesses a valuable perspective on operating within a domestic environment that may be second nature to them, but that may one day also prove useful to other troops going into conflict in similar settings in the future, but who may not have enough experience within those conditions.

“The greatest challenges facing our aeromedical community in our country lies in our geography,” explained Lieutenant Colonel Lina Maria Mateus, head of the Colombian Air Force’s Special Medical Operations Centre.
Colombia is sandwiched between two large bodies of water, is covered in mountains and rainforest, and is dealing with internal militarised strife, meaning medevac is not only an ongoing requirement, but is about as tough to deliver as anywhere else in the world.

“Even if you have all the assets and capabilities together in one centre,” said Mateus, “with highly experienced aircrew and medical crew, it can take a lot of time to recover isolated personnel or soldier in the field – there’s too much rain, too little visibility, too hostile an environment.”

Mateus stressed that there is a big difference between the type of fighting taking place against the FARC in Colombia and the Taliban in the Middle East, but noted that there has emerged a common type of injury which both Colombian and coalition forces must treat.
“Of course, abdominal wounds are very difficult to treat, but the most frequent injury is limb wounds from the IED.
“It’s becoming easier to treat, but in the past we lost many people through blood loss.”

Indeed, the IED injury is only second to “general sickness” for medevac response missions, outweighing the likes of gunshot wounds and even simple accidents.
Aside to domestic terrorism, Colombian medevac teams deal with everything from providing humanitarian assistance – including Earthquake’s in Chile, Haiti, Guatemala and Costa Rica, not to mention its own severe flooding and forest fires – to rescuing mountaineers in the Andes.

To tackle this, the government established the National Personnel Recovery Centre (NPRC) as a joint service pool of resources in 2008, involving the Department of Defence and Department of Health, with equipment support from the US, and it sees advantage in discussing progress with agencies in other nations.

“Nowadays, we have advanced medical group support, which includes general surgeons, orthopaedic surgeons, anaesthetists, and all kinds of resources to treat the patient in that ‘golden hour’,” Mateus explained.

“But we have to hear from other countries because that will help us to establish ourselves as the best at medevac and PR in our region – that’s our goal.”

1 comment:

Jane Morai said...

Hmmm. That's a very interesting question. Thank you for sharing your view on this topic.