Military aeromedical evacuation

Background

• Given the speed of modern warfare coupled with the near absence of a true front line an answer to improving survivability was needed by the United States military
• The solution was a two-pronged approach
  1. life and limb saving damage control surgery/intervention close to the point of injury
  2. Movement of casualties out of austere environment to definitive care quickly
• Utilizing cargo aircraft of opportunity movement of stabilized patients from tactical environment to definitive care occurs in as little as two to three days under the current US military Aeromedical Evacuation system

Types of Patient Movement

• Casualty Evacuation (CASEVAC) - a term used by all branches of the US Department of Defense which refers to the unregulated movement of casualties aboard ships, vehicles, or aircraft.
• Medical Evacuation (MEDEVAC) - a termed used by the US Army, US Navy, and US Marine Corps which refers to the use of predesignated tactical or logistic aircraft, boats, ships, or other watercraft temporarily equipped and staffed with medical attendants for unregulated en route care. Most often the term applies to US Army rotary wing aircraft.
• Aeromedical Evacuation (AE) - a term which specifically refers to the use of vehicles most often US Air Force fixed-wing aircraft for the regulated movement of casualties with trained medical attendants on board. AE aircraft can operate as far forward as fixed-wing aircraft are able to conduct operations.

Patient Movement Process

• A military treatment facility (MTF) provider identifies need to move casualty to higher level of care and completes an AF3899 - Aeromedical Evacuation Patient Record.
• The Patient Administrator submits a Patient Movement Request (PMR) to the Patient Movement Request Center (PMRC) via TRANSCOM Regulating And Command & Control Evacuation System (TRAC2ES).
  • The PMR is based on a completed AF 3899
  • The PMR provides everyone involved in the patient movement process the minimal information needed to ensure safe and timely movement of a patient
  • The PMR needs to provide detailed enough picture concisely to ensure right patient is moved at right time
• The PMRC Validates the request and gives the validated requirements to AE Control Team (AECT).
  • "Clearance" is performed at local level of the MTF
    • Ensures patient and their care is optimized for flight environment
    • Completed by base level Flight Surgeons
  • "Validation" is done at theater level
    • Balances theater airlift efficiency against patient's needs
    • Completed by a Senior Flight Surgeon at the PMRC
• AECT books/plans missions to meet movement requirements.
• Then PRMC manifests patient on mission in TRAC2ES.
• Finally the MTF or Enroute Patient Staging facility (ERPS) ensures patient is ready for mission and transferred to AE Crew on the aircraft.

Patient Classifications

• Reference attached table for specific patient movement category
• Based on diagnosis & ability to egress aircraft in an emergency

Movement Precedence

• Not same as triage categories used to prioritize treatment
• Three Tiered System:
  • URGENT - as soon as possible but no later than 12 hours to save life, limb, eye or prevent serious complications in stabilized patient
  • PRIORITY - within 24 hours if condition will significantly deteriorate and treatment not available locally
  • ROUTINE - next scheduled AE mission usually within 72 hours as condition is stable and not expected to deteriorate significantly given local medical resources

Roles of Local Flight Surgeon

• Assesses AE patients and develops plan of care to ensure patient survives the transport
  • Addresses unique stressors of flight that exist in-flight based on patient's condition and treatments
  • Addresses limitations found in the in-flight environment of care
• Provides and orchestrates local resources to prepare patient for movement
• Serves as the clinical forward observer for the theater validating flight surgeon at the PMRC
• Key duties included
  • Identifying aeromedical significant problems on patient's problem list
  • Pertinent review of patient to anticipate / predict possible deterioration en route
  • Determines what prescriptive measures can prevent flight-related deterioration identified by above steps
  • Assures that ground based care plan has been adjusted for stressors of flight
  • Coordinates with ground treatment team and AE team

Roles of Validating Flight Surgeon

• Serves as medical oversight for utilization of AE resources
• En Route Medical Control in absence of an on-board physician
• Medical Consultant to clearing flight surgeons and originating physicians at local MTF
• Clinical oversight of en route care ensuring safety of patient and quality outcomes
• Oversees rapid, safe movement of patients intra- and inter-theater
• Overall responsibility for all patients in the movement system for their PRMC
• Ensures right patient, right time, right conveyance, right en-route care and right destination

Stressors of Flight

• MAJOR STRESSORS
  • Hypoxia
  • Barometric pressure changes
• IRRITANT STRESSORS
  • Dryness
  • Noise
  • Vibration and turbulence
  • Temperature changes
  • G-forces
  • Fatigue associated with long flights

Rule-Out Clinical (ROC) Indicators List

• Tool used to screen for potential communicable diseases based on five key indicators
• If indicators are present on patient movement request, they suggest a patient suffering from a highly contagious communicable disease
• The indicators are as follows:

1. Positive history of exposure plus any of the other four categories. Exposure to sewage, body fluids, animals or insect bites prior to illness.
2. Fever greater than or equal to 38.9 C or 102.0 F oral.
3. Abnormal bleeding from gums, nose, or petechiae on palate, throat, or mouth
4. Adenopathy. Any report of tender or painful lymph nodes. Any report of lymph nodes "bruised" or dark. "Matted", "Goose egg" or pus-draining lymph nodes
5. Rapid respiratory decline, rashes, skin changes, or other deterioration. Severe decline in less than 3 days from onset. Pox lesions or rash. Petechiae, purpura, icterus. Cough and fever in conjunction with rapid disease progression/petechiae/purpura/lymphadenopathy

• A YES to categories 2-5 should prompt immediate telephone consultation with the Theater Validating Flight Surgeon. YES to category 1 alone does not necessarily require consultation. If in doubt --- CALL.

Forms

AF 3899 Aeromedical Evacuation Patient Record

References

1. DoDI 6000.11 Patient Movement (May 2012 IC1 1December 2017)
2. DoDI 4515.13 Air transportation Eligibility (January 2016 IC 31March2016)
3. AFI 10-2909 Aeromedical Evacuation Equipment Standards (July 2013)
4. Joint Publication 4-02, Joint Health Services Appendix A Patient Movement (December 2017)