During the Vietnam War, it took an average of 45 days to return severe casualties to the United States, and the survival rate was 75 percent. By the time of Operation Desert Storm, in 1991, getting wounded patients home averaged 10 days, but their survival remained stubbornly at 75 percent. Today, the Air Force has gotten the time down to three days or less from virtually anywhere on the planet, and as for the survival rate, “if you make it to a field hospital in theater with a heartbeat,” says Justin Brockhoff, an officer with the Tanker Airlift Control Center at Scott Air Force Base in Illinois, “you have a 98 percent chance of living.”
Two major factors account for the improvement in survival rates. First: Robust and sophisticated en route care, which is part of a continuum of advanced care that begins at the moment of injury—soldiers are trained and equipped to self-administer medical care, including tourniquets and even intravenous fluids. Second, improved evacuation logistics, thanks especially to aviation. Crews now move critical patients more safely and effectively with a wider array of equipment and airplanes. Much of this is orchestrated by planners at Scott, getting data on flights from a variety of sources.
The base is home to the 375th Aeromedical Evacuation Squadron, one of four active-duty aeromedevac units: Another is in North Carolina, one is in Japan, and one is in Germany. But Scott, about half an hour east of St. Louis, Missouri, is also the headquarters of the Transportation Command, the Air Force’s cargo-moving operation. “We’re like the quarterback: We make audible calls. We shift. We’re planning and tasking,” says Brockhoff of Scott’s NASA-style mission control, where banks of military and civilian staff watch flat screens and world maps sprinkled with icons representing airborne cargo, some of it U.S.-bound patients. “We’re here if they run into weather or maintenance problems.”
Scott also runs an Aeromedical Staging Facility, which can accommodate 40 patients overnighting on their way to other points for specialized care or discharge. “The facility is a little bit of home,” says Army Sergeant Leonard Hathaway, a coordinator in a Transportation Command program that welcomes home wounded soldiers. While visiting Scott, I talked to Private Tanner Williams, 20, who had just flown in on a sunny Monday morning. Williams was a member of the Iowa Army National Guard. If you could ignore his cast and crutches, he looked no different from a college kid watching TV in a dorm lounge. Williams had been stationed at Forward Operating Base Kalagush in eastern Afghanistan. The prior Wednesday evening, he had been part of a routine patrol when an improvised explosive device went off beneath his all-terrain vehicle.
“I was instantly out,” he told me, and he didn’t wake up until the helicopters arrived. “I remember getting littered to the chopper.” The first stop in his long aeromedical evacuation was the airfield at Jalalabad. X-rays done there revealed a broken heel, another broken bone in his foot, and stress fractures in his lower vertebrae. He stayed the night, and the next morning flew out to Bagram, where he spent the day, then flew to Landstuhl Regional Medical Center in Germany. “That was by far the best hospital I’ve ever been to,” said Williams, grinning. “Just a really high level of amenities.” After a day and a half at Landstuhl came the long flight to Andrews Air Force Base, outside Washington, D.C., where some severely injured personnel were offloaded to head to other points in the eastern United States. (During the flight, Williams was given a switch to administer his own morphine. “I needed it anywhere from every 20 minutes to two hours,” he says.) Yet another flight brought him to Scott. He will stay until tomorrow morning, then board a C-130 Hercules transport outfitted for aeromedical evacuation. That airplane will make a tour of the Midwest, dropping patients off at various bases. Williams will get off at Fort Hood in Texas for surgery and rehab.
Over the years, aeromedical evacuation has also gotten a boost from what is called universal qualification. “That was a direct result of Desert Storm,” says Rick Stefanski, a medical technician and former Air Force flight tech now working as a civilian at Scott. “Prior to that time, every [medical staffer] was qualified basically in one or two, maybe three different aircraft. And it was seen in Desert Storm that there weren’t enough crews going to different platforms, so that’s when certification was put forth that a flight nurse should be able to fly on any of the certified type of aircraft.” This was formalized by 2002.
Airplanes also lost some of their specialization. Today, a variety of aircraft are used for aeromedical evacuation missions, including the C-130, the KC-135 Stratotanker, and the C-17 Globemaster III. The military also uses the Civilian Reserve Air Fleet: commercial airliners—usually Boeing 767s—that serve as backups to Air Force craft. “While a particular mission might be designated as an ‘aerovac,’ the aircraft is not,” writes Florida Air National Guard physician Bruce R. Guerdan in the fall 2011 issue of the American Journal of Clinical Medicine. “Indeed, you will no longer see the red cross on the tail of any USAF aircraft. Essentially, any USAF non-fighter aircraft can be configured to carry patients.”
“Now it’s any crew and any plane, essentially,” says Colonel Beverly Johnson, the chief of aeromedical evacuation clinical operations and training at Scott. “Whatever plane is out there, we’re taking that one.”
This degree of flexibility was required in 2008 when an Air Force team boarded a KC-135 in Texas to make a pickup at Hickam Air Force Base in Hawaii. The airplane had engine trouble before takeoff, so the team transferred 2,000 pounds of equipment to a C-5 Galaxy, which got them to Hickam to make their pickup: a 12-day-old baby girl with a heart defect. They loaded her and the equipment into a waiting C-17—in flight they kept her alive with an ECMO, or extra-corporeal membrane oxygenation, machine, a device to get oxygen into the patient’s blood—and got her to Rady Children’s Hospital in San Diego, where she had surgery that saved her life.
Much of the improvement in the aeromedical-evacuation survival rates can be attributed to the efforts of Paul “P.K.” Carlton, an Air Force surgeon and pilot who advocated for maximizing medical care in the sky. In 1988, Carlton came up with the idea of critical care air transport teams: basically flying surgical teams with a physician, a critical care nurse, a respiratory therapist, and an array of other nurses and technicians to look after a severely wounded patient in flight. While the idea initially got a slow reception, it gained support when critical care teams responded to crises in the 1990s, such as the bombing of the Khobar Towers in Saudi Arabia. Soon the Air Force was providing an entire intensive care unit for the U.S. president whenever he traveled abroad to less-developed countries.