The Flying Emergency Room

One reason more soldiers are making it home alive.

Wounded service members are taken off a C-17 and brought into Scott, which serves as a hub in moving the injured from the battlefield to U.S. treatment facilities. (USAF / Senior Airman Ryan Crane)
Air & Space Magazine

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The practice of aeromedical transport was also advanced by a more rigorous academic approach. Around 1990, William Hurd, an Air Force Reserve flight surgeon, was given responsibilities for flying sick and injured people long distances. “I’ll just get the reference book,” he recalls saying to himself. “Well, that had never been written before.” In 2003, he and co-editor John G. Jernigan published the book that had been missing: Aeromedical Evacuation: The Management of Acute and Stabilized Patients, which details standards of medical care administered in aircraft.

The book also gives a history of the specialty. In 1910, two Army medical officers, Captain George H.R. Grosman and Lieutenant A.L. Rhodes, used their own money to design the first documented air ambulance. (On its maiden flight, in Fort Barrancas, Florida, it traveled 500 yards and crashed.) The first true evacuation of the wounded in airplanes specifically equipped for the job took place during World War I, when French medical officer Eugene Chassaing transformed military airplanes into air ambulances: In April 1918 at Flanders, Belgium, a modified Dorand II flew two patients side by side in the fuselage. By the end of the war, U.S. Army Major Nelson Driver and Captain William Ocker had converted a Curtiss JN-4 Jenny into a flying ambulance.

Flight evacuation during World War II benefitted from the airplane’s jump in size, range, and reliability. By January 1942, U.S. Army Air Forces C-47s had transported more than 10,000 casualties out of Burma, New Guinea, and Guadalcanal. The next year saw the first intercontinental evacuation flight, with Lieutenant Elsie Ott, an Army Air Forces nurse who had never set foot on an aircraft, overseeing five gravely ill patients on a flight from India to Washington, D.C. A training program for flight nurses was started at Bowman Field in Kentucky; the first class graduated in February 1943.

The Korean War coincided with the debut of the C-124 Globemaster, which could carry 123 patients on litters or 200 ambulatory patients. But it was the helicopter that provided the era’s most important contribution to aeromedical evacuation: “medevac,” or flying the wounded directly from the site of injury to the nearest medical facilities, frequently MASH (Mobile Army Surgical Hospital) units. Since then, MASH units kept growing until they no longer had the flexibility that had been their initial purpose. By the 1990s Bosnia conflict, the MASH was replaced by the Combat Surgical Hospital, or CSH (pronounced “cash”), which might house an emergency room, an operating room, a few intensive care unit beds, and several more standard beds, all run by a couple of surgeons and nurses and an anesthesiologist. Says Johnson: “Instead of having 1,000-bed hospitals in our war zones, we’ve reduced our footprint to 10 beds here and 10 beds here and 25 beds here, and we hub-and-spoke. Because we’re able to clear those beds [with evacuation flights]. Logistically we don’t have to have all the personnel, all those supplies. It’s huge for us. We can quickly move resources.”

Most patients can be moved with standard aeromedical evacuation crews. But up to eight percent need intensive care in the air. One such patient was U.S. Army Sergeant Dan Powers, a squad leader with the 118th Military Police Company. Powers was on his second deployment in Iraq; it was a sweltering day in July 2007, and he was helping train local police at the height of the counterinsurgency strategy, or surge. All at once, an insurgent ran up behind Powers and rammed a nine-inch knife into the right side of his head, just below the rim of his helmet and above his cheekbone. The tip penetrated to the core of his head, passing just below the eye, into a cluster of arteries that feed blood to the right side of the brain.

His men sped him, still conscious and able to speak, in a Humvee to Forward Operating Base Shield. There his wound was wrapped in clumps of gauze, the knife still anchored almost to the hilt. He was then rushed to the city’s Green Zone, where medics loaded him into a helicopter, which took him 50 miles north to Balad Air Base (now Joint Base Balad). Less than two hours had passed since the stabbing when Army Lieutenant Colonel Richard Teff, a physician, took over the care of Powers. His surgical team anesthetized Powers and opened a large portion of his skull. After some discussion with another surgeon, Teff determined that the best course of action was to pull the knife out. Blood began gushing from Powers’ head. By the time Teff found and clamped the ruptured artery, Powers had lost 40 percent of his blood.

Teff relayed details and photos to one of the Army’s top neurosurgeons, Lieutenant Colonel Rocco Armonda at Walter Reed Army Medical Center in Washington, D.C. Armonda pulled over in D.C. traffic, examined the images on his laptop, and told Teff to close Powers up and get him to Washington on the double.

At Al-Udeid Air Base in Qatar, a U.S. Air Force C-17 Globemaster crew was preparing to take off with two Stryker anti-tank missile carriers to another airfield within Central Command. Abruptly they received new orders: They boarded a different Globemaster with a larger fuel capacity and flew it to Balad, landing about two hours later. There they refueled and prepared to take Powers nonstop to Andrews, outside Washington, a 14-hour flight.

Flying directly from Balad to the States was highly unusual. “Most missions do not fly direct from the AOR [area of responsibility; Iraq, in this case] back home, due to the required aerial refueling and extended-duty day,” says Major Corbett Bufton, the Globemaster’s command pilot. But aerial refueling is always available if the mission is critical enough, as was deemed the case with Powers.

Two refuelings were scheduled: one over Turkey and another over the United Kingdom. Powers was loaded on, and swaddled in padding to protect his head from turbulence and engine vibration. At the last minute, a soldier with a gunshot wound to the neck was brought aboard as well. A seven-member critical care transport team for each patient boarded, plus a total of three and a half tons of medical equipment. Bufton was told to avoid turbulence. But he was also told to set the cabin pressure equivalent to an altitude of just 4,000 feet above sea level (the most common cabin pressurization is closer to 8,000 feet). This would reduce the risk that Powers’ frayed blood vessels would reopen, that his brain might swell further, or that tiny pockets of air trapped in his head might expand. Bufton would have to fly the airplane below 26,000 feet, well down from its optimal level—around 35,000 feet—and right into the thunderstorms forecast for eastern Europe that night. “It’s easier to pressurize it to a lower altitude if the aircraft is at a lower altitude,” says Lieutenant Colonel Andrea Gooden, deputy chief of aeromedical evacuation clinical operations and training at Scott. Furthermore, while an emergency depressurization at 26,000 feet could be bad for Powers, it would not be as bad as one at 38,000 feet.

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