1. AE Overview 48R – RSV Training Brian J. Dykstra, Col, CFS, INANG
AANGFS – MRU, Little Rock AFB
24 June 2017

2. 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 (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. Objectives RSV Training for AE AE Overview
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
Medical / Flight Surgeon challenges and responsibilities for AE and AE patient processing
What is AE
Capabilities of AE
Process of AE
Definitions/Acronyms

4. AE Definition
AE is the movement of patients under medical supervision to and between medical treatment facilities by air transportation
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
Integrated control of casualty movement by air transport
Clinical & Ops support personnel to complete the mission
Inflight and ground support personnel; equipment
En route staging capability (ERPSS): ASF/MASF/CASF
ERPSS: En Route Patient Staging System
ASF: Aeromedical Staging Facility
Mobile ASF
Contingency ASF
Air Mobility and Medical Forces
Air Force air mobility and medical forces provide Service assets, in conjunction with the other Services, to form the worldwide patient movement system. AE provides time-sensitive en route care of regulated casualties to and between medical treatment facilities using organic and/or contracted aircraft with medical aircrew trained explicitly for that mission. AE forces can operate as far forward as aircraft are able to conduct air operations, across the full range of military operations, and in all operating
environments. Specialty medical teams may be assigned to work with the AE aircrew to support patients requiring more intensive en route care. "AE is the movement of patients under medical supervision to and between medical
treatment facilities by air transportation.“
This clarifies that to provide patient care in the aeromedical environment, Air Force AE crew members and specialty medical teams receive advanced training and education on the stresses of flight, altitude physiology, and medical equipment designed for the En Route Casualty Care System. See AFDD 3-17, Air Mobility, for a detailed discussion of AE. Within the ERCCS, the Air Force uses its capability to stabilize, prepare, and approve casualties or patients for regulated air transport to ensure they are transported
to the right destinations. The ERCCS provides commanders the ability to evacuate severely wounded or critically ill personnel to definitive health care while providing increasing levels of critical health care along the way and in the least amount of time.
Other Services support key elements of the ERCCS by providing the majority of forward surgical care and rotary wing MEDEVAC. The Air Force ERCCS is the backbone of the en route care system operated by air mobility and medical forces. C2 over medical and mobility forces through the ERCCS resident in the COMAFFOR’s A-staff and the AOC enables near-immediate evacuation, strategic reach, and operational capability upon arrival.

5. Aeromedical Evacuation

6. Guidance
Some Regs:
AFPD 10-29, World Wide AE Ops – Establishes policy and assigns responsibilities for AE Ops
AFI , Vol 1, 2, & 3
AFI
AFTTP
USTC Handbook 41-1 – Global Patient Movement Ops

7. Basic Movement Process
Point of Injury (POI)
CASEVAC (unregulated) to 1st MTF/CSF then MEDEVAC to ASF
TCCET – a CCATT team that’s “Lean & Light” can be used for unregulated missions
At ASF PMR (Patient Movement Request) placed into TRAC2ES (TRANSCOM Regulating Command & Control Evacuation System) to move patient AEROVAC
Request vs Requirement
Physicians at originating or accepting facilities submit requests for movement, timing, destination
Validating Flight Surgeon and PMRC validate those requests into airlift “requirements”
ASF – Aeromedical Staging Facility
En route Care: En route care is the continuation of care during movement (evacuation) within the health service support continuum of care without clinically compromising the patient’s condition. En route care involves transitory medical care, patient holding, and staging capabilities during transport from the site of injury or onset of disease, through successive capabilities of medical care, to a medical treatment facility that can meet the needs of the patient. En route care consists of three phases:
Casualty evacuation (CASEVAC) involves the unregulated movement of casualties aboard ships, land vehicles, or aircraft and typically with no medical attendant providing care beyond SABC.
TCCET
ER/Critical Care physician
CRNA
ER or Critical Care nurse
Point of injury
Un-regulated missions
Dust-offs (Army Black Hawks)
TRAP (Marine Tactical Recovery of Aircraft and Personnel – Osprey)
Medical evacuation (MEDEVAC) refers to dedicated medical evacuation platforms staffed and equipped to provide en route medical care using predesignated tactical or logistic aircraft, boats, ships, and other watercraft temporarily equipped and staffed with medical attendants for en route care.
Aeromedical evacuation (AE) specifically refers to United States Air Force evacuation movement of regulated casualties, using organic and/or contracted mobility airframes, with AE aircrew trained explicitly for this mission.

8. 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
1st question VFS asks is whether patient should fly at all
Validation vs Clearance
Clearance to move by air is done at the MTF, i.e. is patient stable for flight
Validation for AE, located at PMRC
AE clearance is a medical care event; validation is a logistic, not a medical event
But in my experience:
the VFS frequently has some say in clearing the patient as well
The VFS may not have critical care background
Neither the VFS nor many FS’s have really flown AE

9. 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
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
AE airlift planners work closely w/ the PMRC in coordination
AOC identifies and tasks aircraft and resources
Air Mobility Division
The air mobility division (AMD) of the AOC plans, coordinates, tasks, and executes air mobility operations for the COMAFFOR. As one of the five divisions of the AOC, the AMD provides integration of and support for all joint operational air mobility missions, to include AE. The AOC commander provides policy and guidance to the AMD who tasks intratheater air mobility forces through wing and unit command posts when those forces operate from home bases and through applicable forward command and control (C2) nodes such as wing operations centers. The aeromedical evacuation control team (AECT) is one of four teams within the AMD
Aeromedical Evacuation Control Team
Medical personnel trained in AE C2 are attached to the AECT within the AMD of the AOC. The AECT is responsible for AE operational planning, scheduling, tasking, execution, and monitoring in coordination with air mobility controllers. The AECT coordinates airlift support and evaluates available air mobility airframes attached to or transiting the theater to meet theater AE requirements. The AECT coordinates with the J-4 medical branch on the JTF staff and the PMRC on patient movement requirements and priorities. It also works closely with air mobility controllers for pre-planned and immediate intratheater/intertheater airlift requests.

10. 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
Assess appropriateness of AE
Ensure patient stability / stabilized (if CCATT required)
Assess movement precedence – determine priority
Works closely with VFS
Begins/completes the PMR
In my experience, while we flight surgeons (and validating flight surgeons) are supposed to know AE and need to know how to clear patients, including patients that may require CCATT to fly AE, many if not most have NEVER flown and AE mission to see how the process occurs from the hospital/CASF to the jet, the flight and finally from the jet to the CASF/hospital.
May fly as medical attendant if patient requires total care or continuous observation for patient management/medications/treatment but CCATT level of care not necessary
May be challenging depending upon specialty
Many AD Flight Surgeons are GMOs
Many other Flight Surgeons do not have critical care specialty training
At many MTFs, physicians have no AE knowledge. There are many sister service physicians that do not have any Air Force background or knowledge

11. FS Responsibilities Clearing FS must consider:
Ability to travel vs need for definitive care
Flight schedules and prep time
Travel time, including possible stops
Some flights around the AOR make multiple stops
Medical capabilities/resources at any stops
Attendant (medical/non-med) qualifications
- Sometimes patients need to be moved in order to free up facilities depending upon the mission, e.g. some patients may need to move sooner not because they are that critically ill or wounded, but in order to free up bed space at the location they are at

12. PMR
- Patient Movement Record

13. Patient Precedence (Priority)
Urgent
Temporarily “stabilized”
Goal: movement w/n 12 hours
Life, limb, eyesight
ISS – In-system select (cargo mission disrupted to support AE mission)
Most likely needs CCATT / TCCET-E
Priority
Stabilized
w/n 24 hours, can’t wait for next scheduled flight, may be ISS
Routine
Stable, capable of waiting up to 72 hrs on next scheduled mission
The operational impact of classifying a patient “urgent” or “priority” can not be underemphasized since an ISS mission will disrupt other missions as the plane is taken out of service so to speak
TCCET - E
5 person team
Trauma surgeon
Anesthesia provider
Emergency medicine physician
Emergency medicine nurse
OR Tech
Surgery before, during or after flight (C17)
Flies with CCATT

15. Fixed Wing Options

16. Stresses of Flight Altitude/Decreased PaO2 Barometric pressure changes
Thermal changes (especially KC135s and C130s)
Decreased humidity
Noise
Vibration
Gravitational Forces
Long days / Circadian rhythm disturbances
Fatigue

17. Altitude / Hypoxia
Does the patient prior to flight need supplemental oxygen?
Will the patient during flight need supplemental oxygen?
What is the Hgb?
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
8.5-10mg – O2 available
mg – O2 at 2L for flight
<7.0mg – AE VFS approval
Post-Op anemia
9.0-10mg – O2 available
mg – O2 at 2L for flight
<8.0mg – AE VFS approval

18. Decreased Partial Press of O2
Ambient partial pressure of O2 deces with incrsing altitude
Sea level, healthy person O2 sat %
Same person at 8,000ft sats may decrease to ~90%
Altitude hypoxia calculator

19. Barometric Pressure
Complications of increased pressure/volume in body cavities
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
Chest – Pneumothorax – have a Pntx catheter & Heimlich valve
Pain may increase: sinuses, ear drums (descent); GI tract (ascent)
Eye/Globe injuries – air in the globe
Boyle’s Law - The volume of an air cavity increases with lower pressure, so gas expands with altitude
Air filled body cavities: GI tract, lungs, skull, middle ear, sinuses, teeth
Other body parts can have air after injury
The equilibrium of pressure is dependent upon the size of the opening into the cavity, the extent of the pressure changes, the density of pressure of the inside gas and the elasticity of the cavity or chamber walls
Don’t forget JP drains and collection systems to equalize pressure at altitude

20. Decreased Barometric Press at Altitude
ET & Tracheostomy tubes – check cuff at altitude and then upon landing
Consider OG tube for GI decompression – keep vented
Do not use air splints if at all possible, if using need close observation
Vent colostomy bags
De-air saline bags when possible, especially for pressure bags

21. Cabin Altitude Restriction
Altitude restriction requires lower flight level which can lead to:
Increased fuel consumption – enough fuel for mission/flight
Lower altitude decreases speed and increases flight time
May increase turbulence due to weather
Recent studies have shown that altitude restriction has lead to fewer complications post flight most likely due to less inflammatory response
Certainly consider for
Penetrating eye injuries w/ intraocular air
Free air in any body cavity
Severe pulm dz
Decompression sickness
Complication Rates in Altitude Restricted Patients Following Aeromedical Evacuation. Aerosp Med Hum Perform, 2016; 87(4):
CAR traditionally used for trapped gas, decompression sickness, severe pulm dz
Now becoming apparent that at altitude it’s not the hypoxia, but the hypobaria that is the issue. Body factors that contribute to this:
generalized capillary leak
Starling response to altitude
Inflammatory reaction to altitude (thought is that upped cytokine response)
? Bubbles evolving in the tissues, which are pro-inflammatory agent which may cause the release of micorparticles
Bubbles can also induce an ischemia-reprofusion inflammatory leukocyte response
All of this leading to tissue edema which increases intercapillary distance and reduces the tissue oxygen delivery and tissue ischemia
AsMA article: CAR patients had a statistically significant lower number of post-flight complications/procedures.
Parenthetically the cost of CAR, both in $ and duration of flight was not statistically significant
So 3 components of tissue oxygen delivery: Supplemental Oxygen, Hgb, CAR

22. Humidity & Temperature
At altitude, the air is much drier (<1% humidity at altitude) which can affect pulmonary secretions
O2 needs bubbler
Vented patients need the HME
May need to increase IVF rates
C130 & KC135’s are very difficult with temperature control
Significant temperature difference between the top & bottom of the cabin as well as between forward & aft (upwards of 15°)
Also consider temperature during transport to and from plane
Aircraft cabin temp fluctuates considerably depending on the temp outside the aircraft
This is caused by the inability of temp control to respond rapidly and the necessity to open aircraft doors at en route stops
Hyperthermia and hypothermia can be seen with many disease conditions, i.e. burns and some neuro disorders
Hyperthermia increases metabolic rate and hypothremia leads to shivering, both increasing oxygen consumption
If patient is too cold or hot, that can contribute to vasoconstriction or vasodilation affecting tissue oxygenation, blood pressure
Generally after 2 hours of flying time there is <5% relative humidity
After 4 hours, there is <1%

23. 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

24. Vibration Ortho patients Other injuries & surgeries
Fractures
External Fixators
Other injuries & surgeries
Increases muscle fatigue to maintain balance
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
Vibration can also result in tissue vasoconstriction
Can affect alignment and/or positions of set fractures
Can result in increased pain

25. G-Forces For most part not a big deal
G-forces are primarily applicable to the neuro patients
TBI pts can experience transient & marked increases in ICP during take-off & landing
Different planes fly at a different angle of attack at cruise
Consider loading head first – keep head forward facing – minimizes acceleration forces on ICP during take-off & landing
When the aircraft accelerates or decelerates, it is possible that already swollen or bruised brain or spinal cord tissue could experience further damage
These patients are secured on a padded litter w/ a backrest (per AFI ) facing aft for the flight (head forward)

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

27. AE Process Originating MTF determines requirement for AE
MRO/PAD requests patient AE to AELT and PMRC
AELT (AE Liaison Team)
Communicates pt movement requirements
Confirms pt prep
PMRC (Patient Movement Requirement Center)
Validates clinically & administratively
Determines destinations options
Determines appropriate component
Produces Lift and Bed Plan b/t originating & destination MTV
GPMRC-Global Patient Movement Requirement Center: Scott AFB
TPMRC-Theater Patient Movement Requirement Center
EUCOM-Ramstein
PACOM-Hickam
JPMRC-Joint Patient Movement Requirement Center when established
The global patient movement requirement center (GPMRC), located at Scott
AFB, IL, provides medical regulating and aeromedical evacuation scheduling for the
continental United States and intertheater operations and provides support to the
theater patient movement requirements centers. The GPMRC coordinates with
supporting resource providers to identify available assets and communicates transport
to bed plans to the appropriate transportation agency for execution.
In the European and Pacific area of responsibility (AOR), the patient movement
requirements centers (PMRCs) are permanently established functions responsible for
coordination of joint patient movement within the AOR. PMRCs operating in other
GCCs (Geographic Combatant Commanders) are assigned to USTRANSCOM. The AFFOR SG can request a joint patient movement requirements center (JPMRC) be established through the global force management process. USTRANSCOM may transfer tactical control (TACON) of the JPMRC to the GCC. PMRCs are responsible for coordinating with GPMRC for patient movement regulated back to the United States.

29. Contingency AE Structure

30. Process Con’t JFACC (Joint Forces Air Component Commander) AEW MASF
AOC/AECT
Identifies resources
Collaborates w/ PMRC
Decides appropriate airframe
Send ATO to AEW
AEW
Receives ATO, tasks aircrew, launches aircraft to on-load airfield
MASF
Stages pt for evac, supports pt care
Loads pt on aircraft, briefs AE crew on pt load
Notifies AELT, AMD/AECT of departure
Joint Forces Air Component Commander
Air Operations Center
Aeromedical Evacuation Control Team
Patient Movement Center
Air Tasking Order
Air Expeditionary Wing
Mobile Aeromedical Staging Facility
Aeromedical Evacuation Liaison Team
Air Mobility Division

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

32. AE Squadron C2 AECMs AELT Manpower: 8
AFMS officer cmd assigned to OG of the AMW
AECMs
Basic: 2FN & 3AETs (AE Techs); but can be augmented
Requires AEOT support of mission launch, recovery, management, support
Directed by AOC in control of the airlift mission
AELT
Manpower: 2
Immediate coordination b/t user service & USAF AE System
Highly mobile; embedded
C2 – command & control
Aeromedical Evacuation Crew Members
Aeromedical Evacuation Liaison Team

33. AE Squadron AEOT AE Support Cell Manpower: 8
Operational & mission management support to airfields conducting AE ops
Crew scheduling/mgt for AE crews & CCATTs
Coordinates support requirements, aircraft configuration, logistics & support, ramp operations
AE Support Cell
Manpower: 4
Admin, logistical, AGE maintenance, Comms
Aeromedical Evacuation Operations Team
Aeromedical Evacuation Support Cell

34. AE Squadron
AECT
Medical personnel trained in AE command & control attached w/n the AMD of the AOC
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
- Aeromedical Evacuation Control Team

35. Patient Movement Process

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

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

38. QUESTIONS