Aeromedical
Evacuation
Management of Acute
and Stabilized Patients
William W. Hurd
William Beninati
Editors
Second Edition

123


Aeromedical Evacuation


William W. Hurd • William Beninati
Editors

Aeromedical Evacuation
Management of Acute
and Stabilized Patients
Second Edition


Editors
William W. Hurd, MD, MPH, FACOG,
FACS
Col, USAF, MC, SFS (ret.)
Chief Medical Officer
American Society for Reproductive
Medicine

Professor Emeritus
Department of Obstetrics
and Gynecology
Duke University Medical Center
Durham, NC
USA

William Beninati, MD, FCCM
Col, USAF, MC, CFS (ret.)
Senior Medical Director
lntermountain Life Flight and Virtual
Hospital
University of Utah School of Medicine
Salt Lake City, UT
USA
Clinical Associate Professor (Affiliated)
Stanford University School of Medicine
Stanford, CA
USA

ISBN 978-3-030-15902-3
ISBN 978-3-030-15903-0
/>
(eBook)

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Foreword

Killed in action (KIA), died of wounds (DOW), and case fatality (CF) rates
among US service members are at their lowest points in the history of warfare. Directly attributable to this striking rise in survivability are numerous
factors, which include highly effective body armor, widespread use of Tactical
Combat Casualty Care at the point of injury (POI), rapid casualty evacuation/
tactical critical care evacuation from POI to higher levels of medical care,
forward resuscitative surgery, a standardized trauma network that is integrated across all theaters of operation, and aeromedical evacuation (AE) bolstered by Critical Care Air Transport Teams (CCATT). Clearly, all of the
aforementioned capabilities have saved thousands of lives and mitigated
incalculable suffering. The en route care system (a series of clinical and
mobility processes bridged by a command and control system, along with a
network of organizations composed of highly trained, multidisciplinary personnel; machines, technology, and information systems) has been the keystone for the dramatic reduction in the footprint of medical personnel and
infrastructure within the theater of operations. As a result, logistics support is
freed up for other purposes while further advancing the quality of care for our
injured and/or ailing service members. Moreover, whether supporting combat
or humanitarian/disaster relief operations, the en route care system represents
a national capability essential to the security of the United States.

Undoubtedly, America’s national security is based on the appropriate
application of the instruments of national power (diplomacy, information,
military, and economic). However, without the patriotic, courageous, dedicated, and self-sacrificing men and women serving in our nation’s armed
forces, the instruments of national power would be fatally weakened. It is,
therefore, critical for America’s political and military leaders to heed the
advice of Major (Dr.) Jonathan Letterman, Medical Director, Army of the
Potomac, whose innovations still form the backbone of the US military’s
standardized battlefield trauma system, as well as its en route care casualty
evacuation system: “It is the interest of the Government, aside from all the
motives of humanity, to bestow the greatest possible care upon its wounded
and sick, and to use every means to preserve the health of those who are well,
since the greater the labor given to the preservation of health, the greater will
be the number for duty, and the more attention bestowed upon the sick and
wounded, the more speedily will they perform the duties for which they were
employed.” In other words, regardless of the cost, it is incumbent upon the
US Government to provide all the resources required to optimize care for its
v


Foreword

vi

armed service members, and it is incumbent upon the leadership of the
Military Health System to ensure all military medical personnel are resourced,
trained, experienced, and always ready to deliver increasingly sophisticated
healthcare. This must encompass the total spectrum of care required to support the nation’s defenders of freedom, whether it be at home garrison, the
battlefield, and all points in-between. It is to this end this essential textbook
lies. Its contents have been updated by a distinguished panel of experts in
disciplines who collectively and synergistically compose the US military’s

unrivaled en route care system.
Bart O. Iddins, MD, DVM, SM
Maj Gen, USAF, MC, CFS (ret.)
Medical Director, Oak Ridge National Laboratory
Oak Ridge, TN, USA


Preface

Aeromedical evacuation (AE), the long-distance air transportation of patients,
has advanced dramatically since the first edition of this book was published
almost two decades ago. At that time, forward-deployed medical units have
become lighter and more rapidly deployable, and thus have little patientholding capacity. This evolution has made AE an essential element of contingency medical care throughout the world. The reach of AE is global, and it
spans contingencies from humanitarian operations and disaster relief to support for combat operations and the response to terrorism. The second edition
of this book is an update that summarizes much of what has been learned
about important issues that should be considered in planning and executing
long-distance AE.
We asked our expert authors to concentrate on two primary objectives as
they rewrote their chapters. The first objective is to describe the problems
and limitations of medical care in-flight. Ground-based medical teams manage patients before AE and determine the timing of when to request
AE.  Their clinical and operational decisions can have a major impact on
how their patients will tolerate the stresses and limitations of the AE environment. The goal is to increase non-flying clinicians’ appreciation of the
medical flight environment so that they can better select and prepare their
patients for AE.
The second objective is to examine the unique challenges that AE presents for patients with specific medical conditions. This applies to both
elective and urgent AE.  It is especially important for urgent AE, since
recently stabilized patients have less physiologic reserve, and are often
more sensitive to the stresses of flight. To minimize patient risks during
flight, we have asked experts in their fields to provide criteria that patients
with specific conditions should fulfill prior to AE. These experts have also

outlined patient preparation and equipment required for safe air transportation and management of the most likely complications that can occur
during flight.
Years of AE experience transporting stabilized patients who are critically
ill or injured has greatly improved our understanding of the stresses of flight
and the risks to specific patients during long-distance AE. We hope that the

vii


Preface

viii

updated information in this edition will help guide medical planners and
serve as a useful reference for the military and civilian clinicians who prepare
patients for AE, and especially the medical flight crews who take care of them
in the air.
William W. Hurd, MD, MPH, FACOG, FACS
Col, USAF, MC, SFS (ret.)
Durham, NC, USA
William Beninati, MD, FCCM
Col, USAF, MC, CFS (ret.)
Salt Lake City, UT, USA


Disclaimer

The views expressed herein are those of the authors and do not necessarily
reflect the official policies or positions of any agency of the US Government,
including the US Air Force, the US Army, the US Navy, the Department of

Defense, the Department of Veterans Affairs, and the Federal Aviation
Administration.

ix


Contents

Part I The Need
1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
William W. Hurd and William Beninati

3

2

Aeromedical Evacuation: A Historical Perspective . . . . . . . . . . .
Kathleen M. Flarity, Tamara A. Averett-Brauer,
and Jennifer J. Hatzfeld

5

3

Military Casualty Evacuation: MEDEVAC . . . . . . . . . . . . . . . . . 21
Cord W. Cunningham, Donald E. Keen, Steven G. Schauer,
Chetan U. Kharod, and Robert A. De Lorenzo


4

Civilian Air Medical Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
William Beninati, J. D. Polk, and William F. Fallon Jr.

Part II The Means
5

Aircraft Considerations for Aeromedical Evacuation . . . . . . . . . 61
John G. Jernigan

6

Preparation for Long-Distance Aeromedical Evacuation . . . . . . 77
Warren C. Dorlac, Phillip E. Mason, and Gina R. Dorlac

7

Aeromedical Patient Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Lisa Diane DeDecker and William W. Hurd

8

Military Aeromedical Evacuation Nursing . . . . . . . . . . . . . . . . . . 107
Elizabeth Bridges and Melissa A. Buzbee-Stiles

9

Critical Care Air Transport: Patient Flight Physiology
and Organizational Considerations. . . . . . . . . . . . . . . . . . . . . . . . 127

William Beninati and Thomas E. Grissom

Part III The Patients
10

Aeromedical Evacuation of Patients with Abdominal,
Genitourinary, and Soft Tissue Injuries . . . . . . . . . . . . . . . . . . . . 147
Christopher J. Pickard-Gabriel, Raymond Fang, and Jeremy
W. Cannon

xi


Contents

xii

11

Orthopedic Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Russell K. Stewart, Steven L. Oreck, Lucas Teske,
and Brian R. Waterman

12

Aeromedical Evacuation of the Neurosurgical Patient . . . . . . . . 175
Daniel J. Donovan, Matthew A. Borgman,
Rose M. Leary-Wojcik, and Mick J. Perez-Cruet

13


Otorhinolaryngology Head and Neck Surgery Patients . . . . . . . 199
Skyler W. Nielsen, David G. Schall, Joseph A. Brennan,
and John R. Bennett

14

Care of Ophthalmic Casualties . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Nathan Aschel Jordan, Robert A. Mazzoli, Bryan Propes,
and Jo Ann Egan

15

Peripheral Vascular Casualties . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Ryan E. Earnest, Anthony J. Hayes, and Amy T. Makley

16

Aeromedical Evacuation of Cardiothoracic Casualties . . . . . . . . 249
Michael J. Eppinger and Kenton E. Stephens Jr.

17

Burn Casualties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
David J. Barillo, Julie A. Rizzo, and Kristine P. Broger

18

Patients Requiring Mechanical Ventilation . . . . . . . . . . . . . . . . . 289
Dario Rodriquez Jr. and Richard D. Branson


19

Medical Casualties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
J. Christopher Farmer, Thomas J. McLaughlin,
and Robert A. Klocke

20

Aeromedical Evacuation of Patients with
Contagious Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Brian T. Garibaldi, Nicholas G. Conger, Mark R. Withers,
Steven J. Hatfill, Jose J. Gutierrez-Nunez,
and George W. Christopher

21

Aeromedical Evacuation of Obstetric and
Gynecological Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
William W. Hurd, Jeffrey M. Rothenberg,
and Robert E. Rogers

22

Overview of Pediatric and Neonatal Transport . . . . . . . . . . . . . . 363
T. Jacob Lee, Angela M. Fagiana, Robert J. Wells,
Howard S. Heiman, William W. Hurd,
and Matthew A. Borgman

23


Aeromedical Evacuation of Psychiatric Casualties . . . . . . . . . . . 391
Alan L. Peterson, Dhiya V. Shah, Jose M. Lara-Ruiz,
and Elspeth Cameron Ritchie

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403


Contributors

Tamara  A.  Averett-Brauer, MN, BSN Col, USAF, NC.  CFN, En Route
Care and Expeditionary Medicine, Human Performance Wing, Aeromedical
Research Department, USAF School of Aerospace Medicine, Wright
Patterson AFB, Dayton, OH, USA
David  J.  Barillo, MD, FACS, FCCM COL, MC, USA (ret.), Former,
Clinical Division/Director US Army Burn Center, Former, US Army Burn
Flight Team, U.S.  Army Institute of Surgical Research, Joint Base San
Antonio-Fort Sam Houston, San Antonio, TX, USA
Disaster Response/Critical Care Consultants, LLC, Mount Pleasant, SC,
USA
William Beninati, MD, FCCM Col, USAF, MC, CFS (ret.), Senior Medical
Director, Intermountain Life Flight and Virtual Hospital, University of Utah
School of Medicine, Salt Lake City, UT, USA
Clinical Associate Professor (Affiliated), Stanford University School of
Medicine, Stanford, CA, USA
John R. Bennett, MD, FAAO-HNS, FAAFPRS Ear Nose & Throat Center
of Utah, Salt Lake City, UT, USA
Matthew  A.  Borgman, MD, FCCM, CHSE LTC, MC, USA, Pediatric
Critical Care Services, Brook Army Medical Center Simulation Center, Joint
Base San Antonio - Fort Sam Houston, San Antonio, TX, USA

Department of Pediatrics, F. Edward Hebert School of Medicine - Uniformed
Services University, Bethesda, MD, USA
Richard D. Branson, MS, RRT, FAARC, FCCM Department of Surgery,
Division of Trauma/Critical Care, University of Cincinnati, Cincinnati,
OH, USA
School of Aerospace Medicine, Wright Patterson Air Force Base, Dayton,
OH, USA
Joseph A. Brennan, MD, FACS Col, USAF, MC (ret.), Clinical Operations,
Department of Surgery, Uniformed Services University of the Health
Sciences, Annapolis, MD, USA
Elizabeth Bridges, PhD, RN, CCNS Col, USAF, NC (ret.), Biobehavioral
Nursing and Health Informatics, University of Washington School of Nursing,
University of Washington Medical Center, Seattle, WA, USA
xiii


xiv

Kristine P. Broger, DNP, RN, MHA, CCRN, NE-BC LTC, NC, USA, US
Army Burn Flight Team, Nursing, US Army Medical Department, Guthrie
MEDDAC, Fort Drum, NY, USA
Melissa  A.  Buzbee-Stiles, MSN, RN, CEN Maj, USAF, NC, En Route
Medical Care Division, Office of the Command Surgeon, Headquarters Air
Mobility Command, Scott Air Force Base, IL, USA
Jeremy  W.  Cannon, MD, MS, FACS Col, USAFR, MC, Department of
Surgery, Penn Presbyterian Medical Center, Perelman School of Medicine at
the University of Pennsylvania, Philadelphia, PA, USA
Uniformed Services University of the Health Sciences, Bethesda, MD, USA
George  W.  Christopher, MD Col, USAF, MC (ret.), Medical
Countermeasure Systems, Joint Program Executive Office for Chemical and

Biological Defense, Fort Belvoir, VA, USA
Nicholas  G.  Conger, MD Col, USAF, MC, Wright Patterson Air Force
Base, Dayton, OH, USA
Division of Infectious Disease, Department of Internal Medicine, Wright
State University School of Medicine, Dayton, OH, USA
Cord  W.  Cunningham, MD, MPH, FACEP, FAEMS LTC (P), MC, FS,
DMO, USA, Critical Care Flight Paramedic Program, Center for Prehospital
Medicine, Army Medical Department Center and School Health Readiness
Center of Excellence, Joint Trauma System Committee on En Route Combat
Casualty Care, DoD EMS & Disaster Medicine Fellowship SAUSHEC, Joint
Base San Antonio-Fort Sam Houston, San Antonio, TX, USA
Robert A. De Lorenzo, MD, MSM, MSCI, FACEP LTC, MC, FS, USA
(ret.), Faculty Development, Department of Emergency Medicine, University
of Texas Health Science Center at San Antonio, San Antonio, TX, USA
Lisa Diane DeDecker, MS, RN Lt Col, USAF, NC, CFN (ret.), En Route
Critical Care Program, Division of En Route Medical Care, Headquarters Air
Mobility Command, Command Surgeon’s Office, Scott Air Force Base, IL,
USA
Daniel  J.  Donovan, MD, MBA, MHCM COL, MC, USAR, 1252nd
Medical Detachment, Tripler Army Medical Center, Department of Surgery,
University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
Gina  R.  Dorlac, MD Col, USAF, MC (ret.), Critical Care Medicine and
Pulmonary Disease, University of Colorado Health, Fort Collins, CO, USA
Warren  C.  Dorlac, MD, FACS Col, USAF, MC, FS (ret.), Trauma and
Acute Care Surgery, Department of Surgery, Medical Center of the Rockies
and the University of Colorado School of Medicine, University of Colorado
Health, Trauma Services, Loveland, CO, USA
Ryan  E.  Earnest, MD, FACS LtCol, USAF, MC, Surgical Critical Care,
Department of Trauma and General Surgery, University of Cincinnati Medical
Center, Cincinnati, OH, USA


Contributors


Contributors

xv

Jo  Ann  Egan, BSN, MS Department of Ophthalmology, Madigan Army
Medical Center, Tacoma, WA, USA
DoD-VA Vision Center of Excellence, Bethesda, MD, USA
Michael  J.  Eppinger, MD Col, USAF (ret.), Cardiothoracic Surgery,
Department of Surgery, South Texas Veterans Health Care System, San
Antonio, TX, USA
Angela  M.  Fagiana, MD, FAAP Maj, USAF, MC, Neonatal Transport,
Department of Neonatology, Brooke Army Medical Center, Fort Sam
Houston, TX, USA
Department of Pediatrics, F. Edward Hebert School of Medicine – Uniformed
Services University, Bethesda, MD, USA
William F. Fallon Jr, MD, MBA LTC, MC, USA (ret.), Trauma Surgery &
Surgical Critical Care, Summa Health System, Akron, OH, USA
Department of Surgery, Case West Reserve University School of Medicine,
Cleveland, OH, USA
Raymond Fang, MD, FACS Col, USAF, MC (ret.), Department of Surgery,
Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
J. Christopher Farmer, MD, FACP, FCCP, FCCM Col, USAF, MC, FS
(ret.), Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix,
AZ, USA
Kathleen  M.  Flarity, DNP, PhD, CEN, CFRN, FAEN Col, USAF, NC,
CFN, Air Mobility Command, Scott Air Force Base, IL, USA

Emergency Medicine, University of Colorado School of Medicine, UC
Health, Aurora, CO, USA
Brian T. Garibaldi, MD Department of Medicine and Physiology, Division
of Pulmonary and Critical Care Medicine, Johns Hopkins Biocontainment
Unit, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Thomas E. Grissom, MD, MSIS, FCCM Col, USAF, MC (ret.), Department
of Anesthesiology, R Adams Cowley Shock Trauma Center, University of
Maryland School of Medicine, Catonsville, MD, USA
Jose J. Gutierrez-Nunez, MD Col, USAF, MC (ret.), University of Puerto
Rico School of Medicine, Department of Medicine, San Juan Veterans
Administration Medical Center, San Juan, PR, USA
Steven J. Hatfill, MD, MSc, MSc, M.Med Department of Clinical Research
and Leadership, Department of Microbiology, Immunology, and Tropical
Medicine, George Washington University Medical School, Washington,
DC, USA
Jennifer J. Hatzfeld, PhD, RN, APHN-BC Lt Col, USAF, NC, TriService
Nursing Research Program, Uniformed Services University of Health
Sciences, Bethesda, MD, USA
Anthony J. Hayes, BS, MD LT, MC, USN, Department of General Surgery,
Navy Medical Center Camp Lejeune, Camp Lejeune, NC, USA


xvi

Howard S. Heiman, MD, FAAP COL, MC, USA (ret.), Neonatal Transport,
Department of Pediatrics, Neonatal-Perinatal Division, Cohen Children’s
Medical Center of Greater New  York, Northwell Health, New Hyde Park,
NY, USA
William W. Hurd, MD, MPH, FACOG, FACS Col, USAF, MC, SFS (ret.),
Chief Medical Officer, American Society for Reproductive Medicine,

Professor Emeritus Department of Obstetrics and Gynecology, Duke
University Medical Center, Durham, NC, USA
Formerly, CCATT physician and Commander, 445th ASTS, Wright-Patterson
Air Force Base, Dayton, OH, USA
Bart O. Iddins, MD, DVM, SM Maj Gen, USAF, MC, CFS (ret.), Formerly,
Command Surgeon, Air Mobility Command & Air Force Special Operations
Command, Director, Health Services Division, Oak Ridge National
Laboratory, Oak Ridge, TN, USA
T.  Jacob  Lee Jr, MD, FAAP Maj, USAF, MC, Pediatric Critical Care,
Critical Care Air Transport, Department of Pediatrics, Brooke Army Medical
Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, USA
John  G.  Jernigan, MPH, MD Brig Gen, USAF, CFS (ret.), Formerly
Commander, Human Systems Center, Brooks Air Force Base, Texas, San
Antonio, TX, USA
Nathan A. Jordan, MD MAJ, MC, USA, Department of Surgery, Tripler
Army Medical Center, Uniformed Services University of the Health Sciences,
Honolulu, HI, USA
Donald E. Keen, MD, MPH, EMTP MAJ, MC, FS, USA, Army Critical
Care Flight Paramedic Program, Center for Pre-Hospital Medicine, U.S
Army Medical Department Center and School, Joint Base San Antonio-Fort
Sam Houston, San Antonio, TX, USA
Chetan  U.  Kharod, MD, MPH Col, USAF, MC, SFS (ret.), SAUSHEC
Military EMS & Disaster Medicine Fellowship, Emergency Medicine,
Uniformed Services University, Bethesda, MD, USA
Department of Emergency Medicine, San Antonio Military Medical Center,
Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, USA
Robert A. Klocke, MD, FACP Department of Medicine, Jacobs School of
Medicine and Biomedical Education, State University of New  York at
Buffalo, Buffalo, NY, USA
Jose  M.  Lara-Ruiz, MA Department of Psychiatry, University of Texas

Health Science Center, San Antonio, TX, USA
Rose  M.  Leary-Wojcik, DMD, MD Col, USAF, MC (ret.), Oral &
Maxillofacial Surgery, Good Samaritan Clinic, DeLand, FL, USA
Amy  T.  Makley, MD Department of Surgery, University of Cincinnati,
Cincinnati, OH, USA
Phillip E. Mason, MD, FACEP Lt Col, USAF, MC, Department of Surgery,
San Antonio Military Medical Center, Fort Sam Houston, TX, USA

Contributors


Contributors

xvii

Robert  A.  Mazzoli, MD, FACS COL, MC, USA (ret.), Department of
Ophthalmology, Ophthalmic Plastic, Reconstructive, and Orbital Surgery,
Madigan Army Medical Center, Tacoma, WA, USA
Uniformed Services University of the Health Sciences, Bethesda, MD, USA
Former Consultant to the US Army Surgeon General, DoD-VA Vision Center
of Excellence, Bethesda, MD, USA
Thomas  J.  McLaughlin, DO, FACEP Colonel, USAF, MC, SFS (ret.),
Department of Emergency Medicine, Texas A&M University College of
Medicine, Bryan, TX, USA
Department of Emergency Medicine, CHRISTUS Health/Texas A&M Spahn
Emergency Medicine Residency, Corpus Christi, TX, USA
Skyler  W.  Nielsen, BS, DO Capt, USAF USARMY MEDCOM BAMC,
Department of Otolaryngology, San Antonio Military Medical Center, Fort
Sam Houston, TX, USA
Steven L. Oreck, SB, MA, MD CAPT, MC, USN (FMF) (ret.), Department

of History, University of Wisconsin-Madison, Madison, WI, USA
Mick  J.  Perez-Cruet, MD, MS Department of Neurosurgery, Oakland
University William Beaumont School of Medicine, Royal Oak, MI, USA
Alan L. Peterson, PhD, ABPP Col, USAF (ret.), Department of Psychiatry,
Division of Behavioral Medicine, The Military Health Institute, University of
Texas Health Science Center, San Antonio, TX, USA
Christopher J. Pickard-Gabriel, MD Maj, USAF, MC, Anesthesia Critical
Care, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
J. D.  Polk, DO, MS, MMM, FACOEP, FAsMA LtCol, USAF, MC, CFS
(ret.), National Aeronautics and Space Administration, Washington, DC, USA
Department of Policy, George Mason University, Fairfax County, VA, USA
Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
Bryan Propes, MD CDR, MC, USN, Department of Ophthalmology, Naval
Medical Center San Diego, San Diego, CA, USA
Elspeth Cameron Ritchie, MD, MPH COL, MC, USA (ret.), Department
of Psychiatry, Washington Hospital Center, Washington, DC, USA
Julie A. Rizzo, MD, FACS MAJ, MC, USA, Burn Unit, United States Army
Institute of Surgical Research, Fort Sam Houston, TX, USA
Dario  Rodriquez Jr, MSc, RRT, FAARC CMS, USAF (ret.), Research
Health Science, CSTARS, Cincinnati, OH, USA
Department of Aeromedical Research, En Route Care Research Division,
USAF School of Aerospace Medicine, University of Cincinnati, Cincinnati,
OH, USA
Robert  E.  Rogers, MD, FACOG COL, MC, USA (ret.), Department of
Obstetrics and Gynecology, Indiana University School of Medicine,
Indianapolis, IN, USA


xviii


Jeffrey M. Rothenberg, MD, FACOG Obstetrics-Gynecology, St. Vincent
Hospitals, Indianapolis, IN, USA
David G. Schall, MD, MPH, FACS Col, USAF, MC, CFS (ret.), Formerly
Otolaryngology Head & Neck Surgery Consultant to the USAF Surgeon
General, Regional Flight Surgery/Aerospace Neurology, Office of Aerospace
Medicine, Federal Aviation Administration, Des Plaines, IL, USA
Steven G. Schauer, DO, MS MAJ, MC, USA, US Army Institute of Surgical
Research, San Antonio Military Medical Center, Joint Base San Antonio-Fort
Sam Houston, San Antonio, TX, USA
Dhiya V. Shah, PsyD Department of Psychiatry and Primary Care Center,
Division of Behavioral Medicine, University of Texas Health Science Center,
San Antonio, TX, USA
Kenton  E.  Stephens Jr, MD Cardiothoracic Surgery, Denali Cardiac &
Thoracic Surgical Group, Anchorage, AK, USA
Russell K. Stewart, BA Wake Forest School of Medicine, Winston-Salem,
NC, USA
Lucas Teske, MD Department of Orthopedic Surgery, Wake Forest Baptist
Health, Winston Salem, NC, USA
Brian R. Waterman, MD Department of Orthopaedic Surgery, Wake Forest
Baptist Health, Winston Salem, NC, USA
Robert J. Wells, MD Col, USAF, MC, CFS (ret.), Formerly, Department of
Pediatrics, University Of Texas MD Anderson Cancer Center, Houston, TX,
USA
Formerly Commander, 445th ASTS, Wright-Patterson AFB, Dayton,
OH, USA
Mark R. Withers, MD COL, MC, USA (ret.), Office of Medical Support &
Oversight, U.S. Army Research Institute of Environmental Medicine, Natick,
MA, USA


Contributors


Abbreviations

AFB
APHN-BC
Brig Gen
BS
BSN
CAPT
Capt
CEN
CFN
CFRN
CFS
CHSE
CNA
CNS
COL
Col
CPE
CPT
DC
DNP
DO
FAAFPRS
FAAO-HNS
FAAP
FAARC

FACOEP
FACOG
FACP
FAsMA
FACEP
FACS
FACEM
FAEN
FCCP

Air Force Base
Advanced Public Health Nurse, Board Certified
Brigadier General
Bachelor of Science
Bachelor of Science in Nursing
Captain (USN)
Captain (USAF)
Certified Emergency Nurse
Chief Flight Nurse
Certified Flight Registered Nurse
Chief Flight Surgeon
Certified Healthcare Simulation Educator
Certified Nursing Administrator
Clinical Nurse Specialist
Colonel (USA)
Colonel (USAF)
Certified Physician Executive
Captain (USA)
District of Columbia
Doctor of Nursing Practice

Doctor of Osteopathic Medicine
Fellow of the American Academy of Facial Plastic and
Reconstructive Surgery
Fellow of the American Academy of Otolaryngology-Head
and Neck Surgery
Fellow, American Academy of Pediatrics
Fellow, American Association for Respiratory Care
Fellow, American College of Osteopathic Emergency
Physicians
Fellow, American College of Obstetricians and Gynecologists
Fellow, American College of Physicians
Fellow, Aerospace Medical Association
Fellow, American College of Emergency Physicians
Fellow, American College of Surgeons
Fellow, Australasian College for Emergency Medicine
Fellow, Academy of Emergency Nursing
Fellow, American College of Chest Physicians
xix


Abbreviations

xx

FCCM
FS
LT
LTC
LtCol
LTC(P)

MAJ
Maj
Maj Gen
MBA
MC
MD
MHA
MMM
MPH
MS
MSCI
MSIS
MSM
MSN
NASA
NC
PhD
RN
ret.
RRT
SFS
USA
USAR
USAF
USAFR
USN
USNR

Fellow, American College of Critical Care Medicine
Flight Surgeon

Lieutenant (USN)
Lieutenant Colonel (USA)
Lieutenant Colonel (USAF)
Lieutenant Colonel, Promotable (USA)
Major (USA)
Major (USAF)
Major General (USAF)
Master of Business Administration
Medical Corps
Doctor of Medicine
Master of Health Administration
Master of Medical Management
Master of Public Health
Master of Science
Master of Science in Clinical Investigation
Master of Science in Information Systems
Master of Science in Management
Master of Science in Nursing
National Aeronautics and Space Administration
Nurse Corps
Doctor of Philosophy
Registered Nurse
Retired
Registered Respiratory Therapist
Senior Flight Surgeon
United States Army
United States Army Reserve
United States Air Force
United States Air Force Reserve
United States Navy

United States Navy Reserve


Part I
The Need


1

Introduction
William W. Hurd and William Beninati

Aeromedical evacuation (AE), the long-distance
air transportation of patients, has seen dramatic
advancements over the last two decades. As a
result, AE has become an essential linchpin of
contingency medical care throughout the world.
Transportation of casualties from the site of injury
to the highest levels of care has undergone two
key technological revolutions in the last 60 years.
During the Korean and Vietnam conflicts, battlefield and tactical medical evacuation (MEDEVAC)
was greatly improved by the use of helicopters to
augment ground transportation. The ability to
transport seriously wounded soldiers quickly
from the injury site to field hospitals for definitive
surgical care dramatically reduced battlefield
mortality. More recently, during the wars in Iraq

W. W. Hurd (
)

Col, USAF, MC, SFS (ret.), Chief Medical Officer,
American Society for Reproductive Medicine,
Professor Emeritus Department of Obstetrics and
Gynecology, Duke University Medical Center,
Durham, NC, USA
Formerly, CCATT physician and Commander, 445th
ASTS, Wright-Patterson Air Force Base, Dayton,
OH, USA
e-mail:
W. Beninati
Col, USAF, MC, CFS (ret.), Senior Medical Director,
Intermountain Life Flight and Virtual Hospital, University
of Utah School of Medicine, Salt Lake City, UT, USA
Clinical Associate Professor (Affiliated), Stanford
University School of Medicine, Stanford, CA, USA

© Springer Nature Switzerland AG 2019
W. W. Hurd, W. Beninati (eds.), Aeromedical Evacuation,
/>
and Afghanistan, the military medical system has
been transformed by the earlier use of AE for the
transport of both stable and stabilized patients as
soon as possible after definitive therapy. Years of
practical experience has dramatically improved
our ability to maximize in-flight care and minimized the risk of adverse sequelae that can be
associated with transporting these patients.
The majority of military AE remains elective,
where air transportation is reserved for stable or
convalescing patients who will be only minimally
affected by the stresses of air transportation.

Highly trained flight nurses and medical technicians monitor patients in-flight to minimize the
chance that they will experience difficulty during
AE. Elective AE continues to be performed using
a variety of military and civilian aircraft with an
assorted level of medical equipment and personnel
required to deal with the uncommon medical
emergencies that occur in-flight.
The last decade has seen the rapid development
of a robust Urgent AE system as a result of increased
training for AE flight crews and the total integration
of specially trained and equipped Critical Care Air
Transport Teams (CCATT). These highly trained
Operational Support teams are comprised of physicians, critical care nurses, and cardiorespiratory
therapists and their specialized equipment and
remain on standby alert to transport stabilized
patients to higher echelons of care whenever the
need arises. This integrated system for transporting
patients requiring ongoing intensive care greatly
3


4

enhances the US Air Force (USAF) capability to
provide AE to stabilized critically ill or injured personnel anywhere in the world.
The original impetus for enhancing medical
care capability of AE was to minimize the intheater medical footprint, since quality postoperative care and large patient-holding facilities are
difficult to maintain in a contingency environment.
This contemporary AE paradigm has resulted in
continued improvements in the survival of critically ill and severely injured patients throughout

the world—particularly during armed conflicts,
natural disasters, or other catastrophic events.
A great deal has been learned over the last
decade about the optimal preparation for AE of
patients with a broad spectrum of medical and
surgical conditions, both in terms of patient preparation and AE crew preparation. However, not
all of this new information has been well documented, primarily because the clinicians who
have become experts in this type of Operational
Support medicine are not always in environments
conducive to such reporting.
The second edition of this book is an update
that summarizes much of what has been learned
over the last two decades about important issues
that should be considered prior to and during
long-distance AE. Since AE is a complex process
with many steps, we have two primary objec-

W. W. Hurd and W. Beninati

tives. The first is to describe the problems and
limitations of medical care in-flight. The goal is
to increase nonflying clinicians’ appreciation of
the medical flight environment when considering
AE for their patients.
Our second objective is to examine the unique
AE problems and risks for patients with specific
conditions when considering either Elective or
Urgent AE.  This is especially important for
Urgent AE, since it is well appreciated that
recently treated patients are often more sensitive

to the stresses of flight and at higher risk for
decompensation. To minimize patient risks during flight, we have asked experts in their fields to
provide criteria that patients with specific conditions should fulfill prior to AE.  These experts
have also outlined patient preparation and equipment required for safe air transportation and the
most likely complications that can occur during
flight.
Years of AE experience transporting critically
ill patients has greatly improved our understanding of the stresses of flight and the risks to specific patients during long-distance AE. We hope
that this updated information will serve as a useful reference source for both the military and
civilian clinicians who prepare patients for AE
and the medical flight crews who take care of
them in the air.


2

Aeromedical Evacuation:
A Historical Perspective
Kathleen M. Flarity, Tamara A. Averett-Brauer,
and Jennifer J. Hatzfeld

Introduction
The origin of aeromedical evacuation (AE), the
transport of the sick and wounded by aircraft, has
a proud heritage that spans more than 100 years.
The current AE system has been instrumental in
saving thousands of lives in peace, war, contingencies, conflicts other than war, and during humanitarian missions. The resolute progress of AE,
which parallels the advances in human flight, has
been the result of humankind’s desire to avoid the
ultimate sacrifice of death while bravely defending

their country’s vital interests. Although early
development of AE progressed slowly, its many
champions steadfastly believed that air transport
of the wounded could significantly decrease the

K. M. Flarity (
)
Col, USAF, NC, CFN, Air Mobility Command,
Scott Air Force Base, IL, USA
Emergency Medicine, University of Colorado School
of Medicine, UC Health, Aurora, CO, USA
e-mail:
T. A. Averett-Brauer
Col, USAF, NC. CFN, En Route Care and
Expeditionary Medicine, Human Performance Wing,
Aeromedical Research Department, USAF School
of Aerospace Medicine, Wright Patterson AFB,
Dayton, OH, USA
J. J. Hatzfeld
Lt Col, USAF, NC, TriService Nursing Research
Program, Uniformed Services University of Health
Sciences, Bethesda, MD, USA

© Springer Nature Switzerland AG 2019
W. W. Hurd, W. Beninati (eds.), Aeromedical Evacuation,
/>
morbidity and mortality of those injured in battle.
The history of AE began in the early part of the
twentieth century as an important part of military
medicine. In the modern era, AE has risen to new

heights with the implementation of technological
advances in both flight and medicine [1–3].

Before World War I
The concept of moving the wounded by air began
almost simultaneously with the concept of fixedwing aircraft flight. Shortly after the Wright
brothers successfully flew their first airplane, two
US Army medical officers, Captain George H. R.
Gosman and Lieutenant A. L. Rhodes, designed
an airplane built to transport patients [1–3]. Using
their own money, they built and flew the world’s
first air ambulance at Fort Barrancas, FL, in 1910.
Unfortunately, on its first test flight, it only flew
500 yards at an altitude of 100 feet before crashing. This flight, followed by Captain Gosman’s
unsuccessful attempt to obtain official backing
for the project, proved to be only the beginning of
many challenges for this new concept [2, 3].

World War I Era
World War I will not be remembered for the
extent that AE was used, but as a time when air
ambulance design made significant progress by
5


K. M. Flarity et al.

6

trial and error. A French medical officer, Eugene

Chassaing, first adapted French military planes
for use as air ambulances [1, 2]. Two patients
were inserted side-by-side into the fuselage
behind the pilot’s cockpit. Modified Dorand II
aircraft were used on the battlefield in April
1918  in what was the first actual AE of the
wounded in airplanes specifically equipped for
patient movement [1, 2].
The United States also used airplanes for
evacuating the injured from the battlefield in
World War I, but found it difficult to use planes
not suited for patient airlift [1]. Specifically, the
fuselages were too small to accommodate stretchers and the open cockpit exposed patients to the
elements. The US Army Medical Corps used airplanes primarily to transport flight surgeons to
the site of airplane accidents to assist in the
ground transportation of casualties [1–3].
By the end of the War, the US Army recognized the emerging requirement to transport the
wounded by air. In 1918, Major Nelson E. Driver
and Captain William C. Ocker converted a Curtiss
JN-4 Jenny biplane into an airplane ambulance
by modifying the rear cockpit to accommodate a
standard Army stretcher (Fig. 2.1). This allowed

Fig. 2.1 The Curtiss
JN-4 Jenny was
converted to an air
ambulance by removing
the rear cockpit seat.
(USAF photo, 311th
Human Systems Wing

Archives, Brooks
AFB, TX)

the US Army to transport patients by airplane for
the first time [1, 2].

Between the World Wars
The success of the Curtis JN-4 Jenny air ambulances during World War I paved the way for the
further development of AE [1]. In 1920, the De
Havilland DH-4 aircraft was modified to carry a
medical attendant in addition to two side-by-side
patients in the fuselage. Shortly thereafter, the
Cox-Klemmin aircraft became the first aircraft
built specifically as an air ambulance. This airplane carried two patients and a medical attendant enclosed within the aircraft. In 1921, the
Curtis Eagle aircraft was built to transport four
patients on litters and six ambulatory patients.
Unfortunately, in its first year in service, a Curtis
Eagle crashed during an electrical storm, killing
seven people. Despite this apparent setback,
aeromedical transportation continued to progress. In 1922, the US Army converted the largest
single-engine airplane built at the time, the
Fokker F-IV, into an air ambulance designated as
the A-2. In the same year, a US Army physician,


2

Aeromedical Evacuation: A Historical Perspective

Colonel Albert E. Truby, enumerated the potential uses of the airplane ambulances [3]:

• Transportation of medical officers to the site
of aircraft crashes and evacuation of casualties
from the crash back to hospitals
• Transportation of patients from isolated stations to larger hospitals where they could
receive more definitive care
• In time of war, transportation of seriously
wounded from the front to rear hospitals.
• Transportation of medical supplies in
emergencies
Transportation of patients by air began to take
on operational importance as well. In 1922, in the
Riffian War in Morocco, the French Army transported more than 1200 patients by air with a fleet
of 6 airplanes [3]. In 1928, a Ford Trimotor was
converted to an air ambulance capable of carrying six litter patients, a crew of two pilots, a flight
surgeon, and a medical technician [1]. Also in
1928, the US Marines in Nicaragua established
that aircraft used to transport supplies into the
jungle would then be used to evacuate sick and
wounded patients to the rear on the return flight.
This concept proved to be an essential part of
modern AE doctrine.
In the 1930s, a registered nurse and visionary,
Lauretta M.  Schimmoler, believed that 1  day
there would be a need to evacuate the wounded
by air, and for 15  years was a proponent for
establishing the Aerial Nurse Corps of America.
However, not everyone supported this premise.
Mary Beard, RN, the Director of the Red Cross
Nursing Service in 1930, stated, “No one of our
nursing organizations, no leading school of nursing, nor any other professional group, has taken

up this subject seriously and definitely tried to
promote the organization of a group of nurses
who understand conditions surrounding patients
when they are traveling by air” [2, 3]. In 1940,
the Acting Superintendent of the Army Nurse
Corps stated, “The present mobilization plan
does not contemplate the extensive use of airplane ambulances. For this reason, it is believed
that a special corps of nurses with qualifications
for such assignment will not be required” [3].

7

The Surgeon General at the time, Major
General C. R. Reynolds, added, “If commercial
aviation companies require special nurses in any
way, which at present I can’t visualize, this is a
matter which has nothing to do with the Medical
Department of the Army” [3]. AE and flight nursing were yet to prove themselves in the quest to
save lives through air transport.

World War II
At the beginning of World War II, it was commonly believed that air evacuation of the sick and
wounded was dangerous, medically unsound, and
militarily impossible [3]. The Army Medical
Department did not believe that the airplane was a
substitute for field ambulances, even when it was
necessary to evacuate casualties over long distances. The Surgeon for the Army Air Force
Combat Command, Major I. B. March, was concerned that field ambulances would not be sufficient to cover the aerial paths of the Air Forces. In
response, the Surgeon of the Third Air Force,
Lieutenant Colonel Malcolm C. Grow, stated that

the “chief stumbling block in the way of air ambulances has been the lack of interest on the part of
the Army Surgeon General. ...Until he accepts the
airplane as a vehicle for casualty transportation, I
doubt if very much can be done about it” [3].
The war soon demonstrated the necessity of
AE.  Large numbers of casualties needed to be
transported back from distant theaters of war.
Because designated AE aircraft did not exist, the
Army Air Force made it their policy to use
transport planes for AE flights as their secondary mission (Fig. 2.2). Regular transport aircraft
were reconfigured for AE using removable litter
supports (Fig. 2.3) [3]. In this way, aircraft that
had transported troops and supplies to the theaters of operation could be utilized as AE aircraft for the return trip. By January 1942, Army
Air Force C-47 aircraft had transported more
than 10,000 casualties back from Burma, New
Guinea, and Guadalcanal. In 1941, the first Air
Surgeon of the Army Air Force, Colonel David
N.  Grant, advocated AE with airborne competent medical care as a way to increase the speed