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How the Army Developed Its Critical Care Flight Medic Training
The fundamental goal of Army medical evacuation (medevac) is to treat combat-wounded soldiers and decrease the time from the point of injury to surgical intervention.1 Rapid evacuation and early treatment reduces suffering, contributes to saving lives, and has resulted in unprecedented survival rates.2–5
Ground transport was the primary method of casualty evacuation until a helicopter was first used in Burma during World War II.6 During the Korean conflict the Bell H-13—with daylight-only capabilities, limited patient-carrying capacity, no in-flight treatment, and no standard operating procedures or dedicated communications network—evacuated nearly 190,000 combat casualties.5,7
Twenty years later soldiers fighting in the jungles of Vietnam had dedicated Army medevac units deployed to evacuate wounded soldiers and civilians to surgical hospitals.6 Flying the Bell UH-1 they could carry multiple patients inside the aircraft with a medic providing care en route. These unarmed aircraft were hit by hostile fire three times more often than all other helicopters and never stopped flying medevac missions. Dustoff (the call sign specific to U.S. Army air ambulances) units would eventually transport almost 900,000 injured soldiers and civilians.7 Successful evacuation and mortality reduction in Vietnam would be the emphasis for developing civilian air ambulance services.5,6
After Vietnam
The Army spearheaded the use of the helicopter for medical evacuation and essentially left it unchanged after the Vietnam War because military doctrine post-Vietnam focused on the rapid movement of large numbers of casualties from European battlefields.4,7 As a result Army medevac units continued to have one flight medic trained to the level of an EMT-Basic who would need a physician, physician assistant, or critical care nurse to accompany a patient requiring advanced care.8
While Army medevac stagnated during the post-Vietnam era, civilian helicopter emergency medical services (HEMS) grew and developed beyond the Vietnam model. Most civilian services adopted a dual-provider model, with the nurse-paramedic team being the most common, operating under physician medical direction using formalized protocols, standard patient care documentation, and quality improvement processes.4,5 The civilian model was also patient-centric, focusing on providers with advanced skills providing critical care in the helicopter en route from the point of injury to the treatment facility.6 At the same time the Army focused on new helicopters with greater performance and operational ability.5
After more than a decade of war in Southwest Asia, medevac helicopters evolved to become more than flying ambulances shuttling the sick and injured to treatment.7,9 This change did not happen immediately. Medevac units were initially deployed to Iraq and Afghanistan operating essentially as they did in Vietnam. There was no requirement to train flight medics to treat patients requiring critical care before deploying. There was no universally accepted standard medical operating guide (SMOG), and medical direction was often provided by physicians without emergency medical or critical care training.7 Though prehospital care is the first link in the chain of survival, flight medics were expected to perform lifesaving treatment during combat operations without the training required to treat critical patients properly.10
In 2009 Secretary of Defense Robert Gates mandated U.S. medevacs deliver casualties to facilities with appropriate surgical care within one hour after the request for a medevac.7 The golden hour mandate emphasized speed with no mention of improved en-route care.
Soldiers and Civilians
Current civilian helicopter evacuation platforms are routinely staffed by critical care-trained flight paramedics or comparably trained flight nurses. The certified flight registered nurse (CFRN) is an RN with generally 3–5 years of experience working in an emergency department or ICU. The critical care flight paramedic (CCFP) must have attended an accredited paramedic program and typically have worked for 3–5 years in a critical care environment or with a high-call-volume 9-1-1 service and passed the FP-C (flight paramedic—certified) or CCP-C (critical care paramedic—certified) exam. Civilian HEMS most often transports blunt vehicular trauma with shorter evacuation times, whereas current medevac transports have longer evacuation times complicated by multiple penetrating injuries associated with blast trauma, head injuries, and airway compromise.11
The traditional model of moving patients used in Southwest Asia was challenged by the operational environments of Iraq and Afghanistan. There flight medics have cared for pediatric, geriatric, obstetric, general medical, and postoperative critical care patients for prolonged periods of time across large geographic areas.5,6 The average evacuation time in Afghanistan has been around two hours.11 EMT-B flight medics were not trained to care for critically ill patients who were often sedated, intubated, on ventilators, and receiving multiple medication drips via IV pump and possibly also blood products.5 Tail-to-tail flights were often necessary to keep medevac crews available and close to their assigned response areas, and because emergency critical care nurses (ECCNs) were never assigned to medevac units, there was no guarantee one would be available to assist.6,8
Identifying the Need for Critical Care Medics
More than 40 after-action reports identified the lack of flight medics’ critical care skills needed to treat critically ill and injured patients as a key issue and recommended paramedic training as the solution.5,6 Still, nothing changed until one particular unit served in Afghanistan.6
Charlie Company, 1st Battalion of the 168th Aviation Regiment (C-1/168) deployed to Afghanistan in 2009. This Army National Guard unit deployed with 12 UH-60 Black Hawk helicopters from California and Nevada, augmented with three additional Black Hawks and crews from the Wyoming Army National Guard. Most of the flight medics were experienced civilian paramedics. They operated with brigade flight surgeon-approved medical treatment protocols and a unit-developed charting system so they could QI their missions. This patient care report started as a paper product and was eventually converted to an electronic format to be included in the patient’s treatment record so receiving medical staff would know the en-route care provided.6
These patient care reports were used to compare outcomes for patients treated by paramedic-trained flight medics and active-duty units with EMT-Basic-trained flight medics. This retrospective cohort study, approved by the U.S. Army Institute of Surgical Research IRB, reviewed 669 patient records from the Joint Theater Trauma Registry for patients with injury severity scores of 16 or higher.4,11 The study looked at 48-hour survival rates for patients transported to hospitals in Bagram and Kandahar by the medevac unit deployed before C-1/168; C-1/168; and the medevac unit deployed after C-1/168.
The researchers found clinically significant evidence that patients transported by paramedic-trained C-1/168 flight medics had 66% less chance of dying within 48 hours of arrival at Bagram or Kandahar.6,11 In 2011 they published “Impact of Critical Care Trained Paramedics on Casualty Survival During Helicopter Evacuation in the Current War in Afghanistan” in the Journal of Trauma and Acute Care Surgery. The study supported the after-action reports submitted for Operation Enduring Freedom, Operation Iraqi Freedom, and current operations in Afghanistan.
The Solution
The solution was to train Army flight medics to the level of their civilian counterparts and provide additional critical care experience as a way to increase the survivability of combat-wounded soldiers and civilians transported by active-duty medevac units.8,11 To accomplish this a flight medic should be National Registry paramedic-certified and provided with critical care competency and certification per the 2009 International Association of Flight Paramedics position statement.5 Then the Army must maintain a force of critical care flight paramedics that can be augmented by ECCNs and physicians when needed.7
The Army Medical Department Center and School (AMEDDC&S, now called the Army Medical Center of Excellence), the Army School of Aviation Medicine, and the Army Surgeon General made the final determination to train all current EMT-Basic flight medics and all subsequent flight medics to the National Registry paramedic (NRP) certification level and provide additional critical care training before assigning them to medevac units.8 As a result the U.S. Army Medical Corps initiated plans to train and certify all current and future flight medics accordingly and add postparamedic certification in critical care transport training before medevac assignment.6
The critical care flight paramedic program was created at AMEDDC&S in late 2011, with the first class starting in 2012.5,8 The training has three phases, each corresponding to a civilian level of education.6 To qualify for training the soldier has to be a 68W (combat medic) with at least three years of experience, have current CPR and EMT-B certifications, a valid flight physical, and meet Army height, weight, and physical fitness standards. Also, while not required, at least one combat deployment is desired.5
Phase 1 of the training is National Registry paramedic certification and lasts approximately 26 weeks.6 Upon passing the NRP written and psychomotor exams and receiving NRP certification, the soldier transitions to phase 2, the follow-on critical care training.8 This is an eight-week program with didactic and clinical training in hospital intensive care units and rideouts with participating critical care transport ground and air units.
Note the IAFP’s critical care paramedic position statement does not specify how many clinical hours are required for becoming a flight paramedic. However, it does state flight paramedics will successfully complete a critical care education program having didactic and practical sessions where the paramedic demonstrates skills proficiency and participates in clinical rotations.11 The critical care phase is designed to expose the medic to as many types of critical patients as possible.6
After completing phase 2, the future flight medic is sent to Fort Rucker, Ala. to complete phase 3 training prior to departing for their medevac unit. During this final five weeks, the student learns how to be a participating member of a medevac flight crew.6
One of the challenges for a training program of this length is requiring Army National Guard and Reserve candidates to be away from their civilian careers for a minimum of 10 months. There is also the possibility of a newly graduated critical care flight paramedic being deployed immediately after graduating for up to a year. These soldiers could potentially be away from their families, homes, and civilian vocations for two years.6
A home station training option was introduced in 2013 with the understanding that the paramedic and critical care phases could be outsourced to accredited paramedic and critical care programs near future flight medics’ homes. Any phase 1 or 2 program identified would still have to meet Army standards and train the soldier in the same period allotted for in-house training,5,6 but this home station training option provided flexibility for active-duty units to send soldiers to obtain the training without changing duty stations.8 It can be a cost-effective way to train soldiers, keep them close to home, and avoid a permanent change of station.6 Phase 3 is not easily exportable and will remain at Fort Rucker.5
The In-House Evolution
An in-house evolution began as a solution to the National Guard and Reserve need for alternative critical care training for soldiers assigned to medevac units who already possessed paramedic certification. The in-house initial critical care course helps alleviate the backlog of Guard and Reserve paramedics assigned to medevac units waiting for last-minute openings at contracted universities. Eventually the goal is to bring critical care training in house for all active-duty, National Guard, and Army Reserve medics regardless of where they accomplish the paramedic portion.
With command approval, two pilot classes occurred in 2018. The first graduated four Army Reserve students, and the second five Army National Guard students. This upgraded to six classes with 12–35 students by the next year. The plan of instruction entailed a two-week didactic phase using an off-the-shelf critical care text, lesson plans, and test bank. The third week focused on hands-on training with an airway and invasive-procedures cadaver lab and progressively complex patient scenario training in the Transport Medical Training Laboratory (TMTL), an HH-60M helicopter simulator, and forward resuscitation surgical team (FRST) mockup.
Weeks 4–7 were devoted to clinical training. The students were assigned to the surgical ICU at Brooke Army Medical Center (BAMC), the burn ICU at the U.S Army Institute of Surgical Research, the BAMC OR, and critical care transport ambulances operated by Acadian. In the eighth and final week the students returned from clinicals, turned in clinical paperwork, and took a comprehensive FP-C-based exam and the IBSC/BCCTPC FP-C exam, time permitting, before out-processing. The FP-C exam could also be scheduled and accomplished after returning home from training. All the students completed the course without remediation.
In-House Benefits
Bringing the training in house allows selection of instructors who are experienced critical care flight paramedics and augmentation with nurses possessing intensive care training and experience with pediatrics, adults, and burn patients—something that can’t be guaranteed from contracted universities. In-house education also allows the opportunity to bring in subject-matter experts on a variety of topics. We currently have a medical school department chair, a burn surgeon, and an expert toxicologist willing to provide the best possible training to our students because they know what is expected of these medics when they deploy to care for casualties of war.
Integrated training in the aircraft cabin environment using the TMTL exposes students to the stresses of caring for patients in confined spaces under suboptimal conditions with limited resources and time constraints. The TMTL requires students to integrate all their skills using high-fidelity patient simulators in a realistic aircraft environment.8 This life-size HH-60M with incident management system software allows instructors to adjust the stress experience of being inside a real helicopter with sound, wind, smoke, smells, temperature, and various light levels.
Finally, there is the FRST mockup. Here students accomplish patient reports and transfer of care to instructors participating as FRST medical providers and receive postresuscitation and postsurgical patients from these same simulated providers. The training exercises are fast-paced and realistic, testing students’ ability to treat injuries while transporting patients.
The Future
As this in-house program evolves, we hope to provide improved critical care training for Army medevac flight paramedics and send more prepared, better-trained soldiers to provide optimum en-route care. Future conflicts will demand flight medics who can perform patient care across the full spectrum of operations. Medevac will probably continue to treat and transport civilian patients and provide defense support to civil authorities related to disasters and large-scale terrorism.
To accomplish these tasks, Army flight medics must possess the same skill sets as their civilian counterparts, or they will never be truly integrated into the National Incident Management System (NIMS) medical response plan. Critical care-trained flight paramedics play an essential role in keeping combat casualty care on the cutting edge.
References
1. Galvagno SM, Mabry RL, Maddry J, et al. Measuring US Army medical evacuation. J Trauma Acute Care Surg, 2018; 84(1): 150–6.
2. Mabry RL, DeLorenzo R. Challenges to improving combat casualty survival on the battlefield. Mil Med, 2014; 179(5): 477–82.
3. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001–2011). J Trauma Acute Care Surg, 2013; 74(2): 705–6.
4. Mabry RL, Apodaca A, Penrod J, et al. Impact of critical care-trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care Surg, 2012; 73: s32–s37.
5. Mabry RL, De Lorenzo RA. Sharpening the Edge: Paramedic Training for Flight Medics. US Army Med Dep J, 2011 Apr; 92–100.
6. Smith BD. Advances in Military Medic Training. EMS World, 2015 Mar; 44(3): 46–50; www.emsworld.com/article/12041100/advances-in-military-medic-training.
7. Olson LCM, Bailey CJ, Mabry LR, et al. Forward aeromedical evacuation. J Trauma Acute Care Surg, 2013; 75.
8. Davids NB. Shaping the flight paramedic program. US Army Med Dep J, 2016 Apr; 48–51.
9. Rodriguez JE. Realistic training for flight paramedics. U.S. Army, www.army.mil/article/172592/realistic_training_for_flight_paramedics.
10. U.S. House Armed Service Committee. LTC Mabry issues statement on ensuring medical readiness in the future. Washington, D.C.: Targeted News Service, 2016.
11. Holland SR, Apodaca A, Mabry RL. Medevac: survival and physiological parameters improved with higher level of flight medic training. Mil Med, 2013; 178(5): 529–536.
Sidebar: Army Equipment
Soldiers attending the in-house critical care program receive training in the operation of Army medical equipment they will use in their medevac units. Soldiers enrolled in civilian critical care programs are not guaranteed exposure to Army equipment or procedures. They use the equipment provided by the university, EMS service, or hospital where they accomplish their clinical training. The Army cannot mandate the civilian programs train the soldiers with Army-equivalent equipment. Soldiers training at civilian programs have to learn to use Army equipment while accomplishing their follow-on phase 3 flight crew training at Fort Rucker. Soldiers receiving phase 2 critical care training in-house have already been working with Army equipment in the classroom, skills labs, simulator, and clinical environments before arrival at Fort Rucker.
Robert Sippel, MAEd, MAS, NRP, FP-C, is a critical care flight paramedic instructor at the U.S. Army’s Medical Education Center and School and an assistant professor with the Uniformed Services University, with experience as a ground and flight paramedic.
Marla Garza, MEd, CCEMT-P, is program manager for the U.S. Army’s critical care flight paramedic program.
Anthony Marchi, MS, NRP, FP-C, is an instructional trainer for 1Prospect Technologies at Fort Sam Houston, Tex., and former instructional trainer and educational systems manager for the U.S. Army’s 187th Medical Battalion.
Sabas Salgado, MSNEd, MBA-HCM, RN, is director of the U.S. Army’s critical care flight paramedic program and manager of the en route critical care nurse (ECCN) program.
Comments
I was one of four Flight Medics at Bagram during that C Co 1/168th GSAB (MEDEVAC) mission. In 2010, I wrote, MEDEVAC: Critical Care Transport from tge Battlefield. That paper was published in 2010 by the American Association of Critical Care Nurses publication: Advanced Critical Care in the July-September issue. In that paper, I provided a detailed first hand perspective of the Flight Paramedic experience that you wrote about during the very mission that established the disparity of Flight Medic training and experience at that time.
—Ruben Higgins