Four Marines who were injured when an improvised explosive device
struck their military vehicle were flown by helicopter to the hospital,
which is located on a former Iraqi air base now occupied by both the
U.S. Air Force and Army.
Three of the Marines sustained serious head injuries and were intubated.
The fourth Marine was conscious and had shrapnel wounds on the right
side of his face and burn and shrapnel wounds on his hands and arms.
All four were taken to ICU #1, one of many small patient units in this
sprawling tent field hospital.
The Marines with
head wounds had undergone surgery. Although the men were still critically
ill, the flight surgeon and the physician intensivist
decided to transfer them via a five-hour aeromedical evacuation
flight to Landstuhl Regional Medical Center — the U.S. military
hospital in Germany.
Shortly after the
patients had arrived in the Balad ICU, a specialized critical care
team consisting of critical care nurse Maj. Kathleen
Fay, RN, with the 914th Aeromedical Staging Squadron from
Niagara Falls, N.Y.; emergency medicine physician Col. Daniel Houssiere,
DO; and respiratory
therapist Master Sgt. Danny Avella arrived to prepare or “package” the
patients for the flight.
The members
of the trio, called a critical care air transportation team (CCATT)
by the Air Force, worked swiftly and precisely, assessing
the patients, checking medical tests and lab work, and
ensuring that indwelling catheters, IVs, and dressings were in place.
Small,
portable life-support and monitoring equipment that
had been flight-tested was attached to black metal frames
resembling hospital tray tables. The tables, called
“SMEEDS,” were latched over the patients and onto their litters.
The patients were
readied for transfer in about 15 minutes each, less than the average
30 minutes per patient it usually takes to prepare
CCATT patients — an indication of the experience of the team,
says Air Force Lt. Col. Ruth Espinoza, RN, the CASF’s chief operations
officer on nights, who is with the 81st Medical Operations
Squadron from Keesler Air Force Base in Mississippi.
The Marines were transported by an ambulance bus to the flight line
and into a waiting cargo jet adapted for patient evacuation. The CCATT
team provided care exclusively for the three Marines during the trip
to Germany. The approximately 40 less seriously ill or injured patients
were cared for by an aeromedical evacuation flight crew.
CCATTs are one
of the key advancements responsible for the highest survival rate
of combat-wounded service members in any U.S. military
conflict. Combined with small, elite surgical/trauma teams
positioned on the ground and close to the battlefield, the Air Force’s
aeromedical evacuation system (AES) can move the grievously wounded
from battlefield
to field hospital to Germany to the U.S. in record-breaking
time.
“We have achieved an astonishing turnaround time, as short as
36 hours, from the battleground to [U.S.] medical care sites — unheard
of even a decade ago,” Air Force Surgeon General Lt. Gen. George
P. Taylor Jr. told a subcommittee of the Committee on Armed
Services, U.S. House of Representatives, in March.
In 2004 the Air
Force handled almost 29,000 patient movements [not individual patients,
but rather legs of flights], of which 4,500 were
for patients with battle injuries, according to Gen. Taylor’s
testimony. “About 79% of all patient movements involved patients
who were in critical or guarded status requiring mechanical ventilation,
IV fluids, pain medications, or cardiac monitors,” he told members
of Congress.
The CCATT concept was developed after the Gulf War when military medical
experts realized they needed to transfer critically injured soldiers
faster and further from the battlefield to definitive medical care
than the existing evacuation system could provide.
“Military medicine needed to move at the speed of modern warfare,” says
Capt. Daniel Moore, RN, BSN, CCATT coordinator and nurse
manager of the 59th Medical Wing at Lackland Air Force Base in Texas.
The 59th
Medical Wing is responsible for the clinical component
of CCATT missions Air Force-wide.
“We truly have extended the ‘golden hour’ of treatment,” says
Moore. During the Gulf War, 22% of injured soldiers would
die, he added. That rate is now below 10%. No CCATT patients have
died during transport
since the start of the war against terrorism, he says.
Such critically
wounded soldiers had never been moved by air before and would not
be moved during peacetime now, says Joseph Schmelz, RN,
a nurse researcher at the Air Force’s Wilford Hall Medical Center
in San Antonio, who is part of a team studying the effectiveness of
CCATTs during wartime. “These are newly injured soldiers in the
process of getting stabilized, but they are not there yet.
The major holes are plugged up, but they are not stable.”
But the CCATTs
are only one important link in the AES chain out of Iraq and Afghanistan.
Almost all service members who are wounded or
injured or fall ill in Iraq and Afghanistan are transferred
to Balad’s
Air Force Theater Hospital, usually by helicopter, and
then to the 332nd Aerospace Medicine Squadron/CASF, operated by personnel
from
Andrews and Keesler Air Force bases, before being transferred
to Germany.
Balad was chosen as the hub for the wounded in part because its long
runways enable any size aircraft to land and because the Air Force
hospital is located here.
Patients brought to Balad are evaluated at the hospital to determine
if they are fit to fly or if they need to remain at the hospital a
day or two for further treatment.
Despite the daily headlines about the number of service members killed
in combat, the majority of patients who come to the hospital and CASF
suffer non-battle- related problems, such as chest pain, hernias, tumors,
or meniscal tears.
A few hours before an aeromedical mission is ready for departure,
patients are taken to the nearby CASF by ambulance bus for final preparations
and medical assessments.
Good nursing care
lies at the heart of the AES, whether it’s
provided by CCATT RNs, flight nurses, CASF nurses, or the
medical technicians who function as LPNs. Working within the AES
requires flexibility,
communication, attention to detail, and, above all, concern
for safety.
At the CASF, providing continuity of care is the responsibility of
the CASF nurses, who must cope with the variables of providing war-time
health care, such as a patient census that can change from one minute
to the next or aircraft that is grounded in another country.
CASF nurses “pre-flight” patients,
ensuring they have the proper medications to take with them, their
dressings are reinforced,
and any IVs, tubes, and drains are patent.
A couple of hours before departure, patients are loaded
onto an ambulance bus for the brief ride to the flight
line. Nurse officers of the day (NODs) give report to the aircraft’s
medical crew director, also a flight nurse.
During
a June 7 AES mission, NOD Lt. Jessica Brantner, RN, from Keesler’s
medical-surgical squadron, wore goggles, earplugs, and
a reflective waist belt as she walked toward the open
back of a C-130 aircraft,
where Maj. Sherman Free, RN, a medical crew director from
the 94th Aeromedical Evacuation Squadron at Dobbins Air
Force Base in Georgia,
was waiting.
During
Brantner’s report, Free asked her about one
patient’s
IV fluids, the amount of Phenergan another service member
had received, and any recent discomfort in a patient complaining
of chest pain. “You want to make sure patients are stable so nothing happens
in the air,” says Free. “If I feel the patient is unstable,
I have the right to refuse the patient. The patient’s welfare
is most important in aviation medicine.”
CCATT nurse Fay had little time to spare on the June 9 flight from
Balad with the three critically injured Marines. Any number of problems
could have arisen during the five-hour flight to Germany.
“A CCATT nurse needs a good understanding of how altitude physiology
challenges the hemostasis of patients in flight,” says Fay. “As
you go higher up in altitude, the barometric pressure decreases
around you, which causes any abnormally trapped air within the body
to expand
a little. That can cause increased pressure.”
Decreased barometric pressure can cause problems for patients with
respiratory or cardiac difficulties, requiring supplemental oxygen.
Other stressors of flight include noise, gravitational and acceleration
forces, and vibration of the aircraft.
Monitor alarms
are difficult to hear on the aircraft, so patients must be constantly
visually assessed. Flight nurses’ best tools
are their own gut instincts, experiences, and careful observations,
Fay says.
“The environment of care for CCATT nurses has a major effect
on how they deliver care,” says Schmelz. “It takes a very
special person to be comfortable in that kind of environment.”
When the aircraft
landed at Ramstein Air Base in Germany, the three Marines were carried
from the aircraft first and loaded into another
ambulance bus for the short ride to Landstuhl Regional
Medical Center. Fay accompanied them to the hospital’s ICU and didn’t leave
until they were safe in the hands of the unit’s nurses and physicians.
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