1. I n t e g r i t y - S e r v i c e - E x c e l l e n c e 122 nd MDG 48R – RSV Training Brian J. Dykstra, Col, SFS, INANG AE Overview

2. Indiana Air National Guard Disclaimer The content is mine and not official DoD, USAF, or ANG doctrine/policy I used notes and pictures from other sources on the Kx exchange as well as the internet I have been deployed as a CCATT doc in Balad 2007, Bagram 2008, Ramstein 2011, and as a SME in Bagram/Kuwait 2014-15 (while deployed as a SME I flew a number of AE missions on C130s), March ‘15 I flew the weekly PACAF AE mission I have no commercial relationships or any conflicts of interest

3. Indiana Air National Guard Objectives RSV Training for AE o Medical Clearance for AE (perform 5); suitable substitute if unable to perform clearances: Read relevant sections of Flight Surgeon’s Guide and SGP Tactics Guide AE Overview o Medical / Flight Surgeon concerns and responsibilities for AE and AE patient processing o What is AE o Capabilities of AE o Process of AE o Definitions/Acronyms

4. Indiana Air National Guard AE Definition AE is the movement of patients under medical supervision to and between medical treatment facilities by air transportation o AE specifically refers to United States Air Force evacuation movement of regulated casualties, using organic airframes, with AE aircrew specifically trained for this mission Capabilities o Integrated control of casualty movement by air transport o Clinical & Ops support personnel to complete the mission o Inflight and ground support personnel; equipment o En route staging capability (ERPSS): ASF/MASF/CASF

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6. Guidance Some Regs: o AFPD 10-29, World Wide AE Ops – Establishes policy and assigns responsibilities for AE Ops o AFI 41-307 o AFI 10-2912 o AFTTP 3-42.5

7. Indiana Air National Guard Basic Movement Process Point of Injury (POI) CASEVAC to 1 st MTF/CSF then MEDEVAC to ASF At ASF PMR (Patient Movement Request) placed into TRAC 2 ES (TRANSCOM Regulating Command & Control Evacuation System) to move patient AEROVAC Request vs Requirement o Physicians at originating or accepting facilities submit requests for movement, timing, destination o Validating Flight Surgeon and PMRC validate those requests into airlift “requirements”

8. Indiana Air National Guard Basic Movement Process Con’t Validation by FS (VFS) occurs at PMRC (Patient Movement Requirement Center) VFS brings medical leadership and decision making to the process of prioritizing use of aviation assets o 1st question VFS asks is whether patient should fly at all Validation vs Clearance o Clearance to move by air is done at the MTF, i.e. is patient stable for flight o Validation for AE, located at PMRC o AE clearance is a medical care event; validation is a logistic, not a medical event

9. Indiana Air National Guard Basic Movement Process Con’t Transformation from a request into airlift requirement: the Patient Movement Clinical Coordinator (PMCC) at the PMRC obtains necessary clinical data and medical equipment requirements from attending physician prior to manifesting patient for movement PMRC provides medical regulating and AE scheduling for transport to next higher level of care o AE airlift planners of AE Control Team (AECT) w/in Air Mobility Division (AMD) of the Air Operations Center (AOC) recognize and respond only to validated requirements o AE airlift planners work closely w/ the PMRC in coordination AOC identifies and tasks aircraft and resources

10. Indiana Air National Guard FS Responsibilities Local clearance authority, i.e. is patient physiologically ready for air travel & Category (urgent, priority, routine) May fly as medical attendant (MA) if necessary If at an ASF (Aeromedical Staging Facility): Evaluates/manages patients Interacts w/ originating physician by defining level of care & care plan en route o Assess appropriateness of AE o Ensure patient stability / stabilized (if CCATT required) Assess movement precedence – determine priority Works closely with VFS Begins/completes the 3899 - PMR

11. Indiana Air National Guard FS Responsibilities Clearing FS must consider: o Ability to travel vs need for definitive care o Flight schedules and prep time o Travel time, including possible stops Some flights around the AOR make multiple stops o Medical capabilities/resources at any stops o Attendant (medical/non-med) qualifications

12. Indiana Air National Guard 3899 - PMR

13. Indiana Air National Guard Patient Precedence (Priority) Urgent o Temporarily “stabilized” o Goal: movement w/n 12 hours o Life, limb, eyesight o ISS – In-system select (cargo mission disrupted to support AE mission) o Most likely needs CCATT Priority o Stabilized o w/n 24 hours, can’t wait for next scheduled flight, may be ISS Routine o Stable, capable of waiting up to 72 hrs on next scheduled mission

14. Indiana Air National Guard Fixed Wing Options

15. Indiana Air National Guard Stresses of Flight Altitude/Decreased PaO2 Barometric pressure changes Thermal changes (especially KC135s and C130s) Decreased humidity Noise Vibration Fatigue Gravitational Forces Long days

16. Indiana Air National Guard Altitude Restriction Altitude restriction requires lower flight level which can lead to: o Increased fuel consumption – enough fuel for mission/flight o Lower altitude decreases speed and increases flight time o May increase turbulence due to weather

17. Indiana Air National Guard Altitude / Hypoxia Does the patient prior to flight need supplemental oxygen? Will the patient during flight need supplemental oxygen? What is the Hgb? o If Hgb <8mg/dL, can only transport if anemia is chronic & stable and not related to bleeding, if Hct <25% need VFS concurrence Chronic low Hgb o 8.5-10mg – O 2 available o 7.0-8.5mg – O 2 at 2L for flight o <7.0mg – AE VFS approval Post-Op anemia o 9.0-10mg – O 2 available o 8.0-9.0mg – O 2 at 2L for flight o <8.0mg – AE VFS approval

18. Indiana Air National Guard Humidity & Temperature At altitude, the air is much drier which can affect pulmonary secretions o O 2 needs bubbler o Vented patients need the HME C130 & KC135’s are very difficult with temperature control o Significant temperature difference between the top and bottom of the cabin Also consider temperature during transport to and from plane

19. Indiana Air National Guard Barometric Pressure Complications of increased pressure/volume in body cavities o Abdominal surgery Abdominal compartment syndrome Respiratory embarrassment pushing up on the diaphragm Decreased blood return to the chest leading to decreased cardiac output due to compression of great vessels in abdomen and increased intrathoracic pressure Ostomy bags – need to vent collection bags o Chest Pneumothorax – Need a Heimlich valve o Pain may increase – sinuses, ear drums ET & Tracheostomy tubes – check cuff at altitude and then upon landing Eye/Globe injuries – air in the globe

20. Indiana Air National Guard Vibration Ortho patients o Fractures o External Fixators Other injuries & surgeries Increases muscle fatigue to maintain balance o May result in increased lactate due to muscular use which can then increase need for minute ventilation – is the patient capable to meet this demand for increased ventilation

21. Indiana Air National Guard G-Forces For most part not a big deal G-forces are primarily applicable to the neuro patients Different planes fly at a different angle of attack at cruise Generally keep head forward facing

22. Indiana Air National Guard Noise Increases stress & fatigue Difficult to communicate – both from patient to AE crew and amongst AE crew Make sure patients have ear protection, especially important for those who can’t insert the foamies

23. Indiana Air National Guard Fatigue Due to the overall stresses of flight, even if patient is relatively stable the stresses of flight can lead to increased fatigue o Noise o Vibration o Temperature changes o Low humidity o Long day o Long flight

24. Indiana Air National Guard AE Process Originating MTF determines requirement for AE o MRO/PAD requests patient AE to AELT and PMRC AELT (AE Liaison Team) o Communicates pt movement requirements o Confirms pt prep PMRC (Patient Movement Requirement Center) o Validates clinically & administratively o Determines destinations options o Determines appropriate component o Produces Lift and Bed Plan b/t originating & destination MTV

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26. Contingency AE Structure

27. Indiana Air National Guard Process Con’t JFACC (Joint Forces Air Component Commander) o AOC/AECT Identifies resources Collaborates w/ PMRC Decides appropriate airframe Send ATO to AEW AEW o Receives ATO, tasks aircrew, launches aircraft to on-load airfield MASF o Stages pt for evac, supports pt care o Loads pt on aircraft, briefs AE crew on pt load o Notifies AELT, AMD/AECT of departure

28. Indiana Air National Guard AE System Components AE Squadron o C2 o AECMs (AE Crew Mbrs) o AELT (AE Liaison Teams) o AEOT (AE Operations Teams) o AE Support Cell o AECT (AE Control Team) o AEOC (AE Operations Center) Ground Medical/MTFs o Support Equipment o Specialized Equipment o ERPSS (En Route Patient Staging System)

29. Indiana Air National Guard AE Squadron C2 o Manpower: 8 o AFMS officer cmd assigned to OG of the AMW AECMs o Basic: 2FN & 3AETs (AE Techs); but can be augmented o Requires AEOT support of mission launch, recovery, management, support o Directed by AOC in control of the airlift mission AELT o Manpower: 2 o Immediate coordination b/t user service & USAF AE System o Highly mobile; embedded

30. Indiana Air National Guard AE Squadron AEOT o Manpower: 8 o Operational & mission management support to airfields conducting AE ops o Crew scheduling/mgt for AE crews & CCATTs o Coordinates support requirements, aircraft configuration, logistics & support, ramp operations AE Support Cell o Manpower: 4 o Admin, logistical, AGE maintenance, Comms

31. Indiana Air National Guard AE Squadron AECT o Medical personnel trained in AE command & control attached w/n the AMD of the AOC o Responsible for: Ops planning Scheduling Tasking Execution Monitoring in coordination w/ air mobility controllers Coordinates w/ the J-4 medical branch on the JTF staff and the PMRC on patient movement requirements and priorities

32. Indiana Air National Guard 32 Patient Movement Process

33. Indiana Air National Guard Patient Classification 1 – Psych o 1A – severely ill, requiring close supervision: sedated, restrained, on a dressed litter o 1B – mod to severely ill: sedated, litter, restraints available o 1C – cooperative, reliable, mod severe psych inpatient traveling ambulatory status Litter categories o 2A – who may or cannot ambulate and may be unable to perform self care, requires assistance in event of emergency o 2B – able to ambulate and sit in a seat, should be able to ambulate in event of an emergency

34. Indiana Air National Guard Patient Classifications con’t Ambulatory categories o 3A – Inpatient, non-psych, requirement medical treatment, assistance or observation en route (usually minimal), or returning from inpatient visit at a MTF o 3B – Recovering inpatient, returning to home station, requires no medical attention en route o 3C – Ambulatory drug or alcohol substance abuse inpatient going for treatment Infant categories: 4A – E Outpatient categories: 5A-F Attendant categories o 6A – medical attendant (physician, nurse, tech) o 6B – non-medical attendant

35. Indiana Air National Guard QUESTIONS