Michael's Dispatches

Army Dustoff Medics Unprepared

“After more than 9 years of conflict and more than 40 AAR’s recommending the evolution of MEDEVAC to current civilian standards, no institutional change has been made. Continuing the legacy model has resulted and continues to result in documented sub-optimal outcomes and increased deaths among patients transported by helicopter in the current conflict.”

Robert L. Mabry, FS, EMT-P
Lieutenant Colonel, MC
JTTS Medical Director, Enroute Care

23 February 2012

The United States Army has failed with extraordinary dexterity while executing the helicopter MEDEVAC plan in Afghanistan.  On the surface, the Army advertisement campaign sells a story that their performance is exemplary and unprecedented in the history of war.  The press machine churns out sound bites, which are picked up in major media without the barest pretense of auditing.  For instance, senior Army officers saying and committing to writing that the Army has achieved a 92% success rate on MEDEVAC.  The Army peddles this message, and yet nobody says, “Show me the money.  Where do you get these figures?”  There is growing evidence that the 92% figure is hollow and fraudulent.

For instance, in an internal memorandum, the issue of poor or nonexistent tracking is repeatedly hammered:

“Further, no systems exist that capture adverse outcomes, protocol violations or sub-standard care outside of the individual MEDEVAC unit or GSAB. Lack of patient care documentation in the medical record and trauma databases is the greatest hindrance to developing data needed to drive improvements in MEDEVAC care.”

Just how the Army derives a “92% success rate” (whatever that is) with data that it fails to track is unknown.

Another Army talking point is that the Dustoff MEDEVAC community is “purpose built” for MEDEVAC, and are the crème de la crème providers in Afghanistan.  Yet this same memorandum states in clear terms that of the three principal MEDEVAC/CASEVAC providers in Afghanistan (Dustoff, Air Force Pedro, British MERT), the Army comes in last place with substandard, archaic procedures and woefully undertrained flight medics.

Excerpted highlights:

**US Army flight medics, credentialed at the National Registry of Emergency Medical Technician-Basic (EMT-B) level, are not trained to perform critical care transport or aggressive advanced resuscitation at the point of injury like their civilian flight paramedic counterparts operating in CONUS [Continental United States].

**Current MEDEVAC staffing model is outdated and based on Cold War / Vietnam [era] doctrine.

**The current capability gap has been documented in more than 40 AAR’s [After Action Reports] since 2002 in both Iraq and Afghanistan. Lack of advanced flight medic capability has directly resulted in poor outcomes in multiple cases and was the impetus for the deployment of critical care nurses to fill this capability gap as well as the deployment of a physician medical director. A recent study that compared critical care trained flight paramedics from a US Army National Guard air ambulance unit versus the conventional MEDEVAC systems operating in OEF [Afghan War] showed a 66% reduction in death at 48 hours post-injury in severely injured patients. Several recent cases illustrate the complexity and acuity of patients currently being managed by a single EMT-B flight medic.  [Dustoff flies with a single medic.  Air Force Pedro flies with a minimum of two medics per bird (often three) who are on average more highly trained.]

** Discussion: Significant variability in unit capability performing MEDVAC exits in the AO [Area of Operations]. The operational units have attempted to fill the capability gaps of our current MEDEVAC model with ad hoc methods that are not standardized and often have significant operational limitations. This creates a situation where different units/personnel have to be used for different missions. Further, no US Army standard treatment protocols exist, as these are significantly variable across different units. This variable capability degrades the MEDEVAC commander’s flexibility to respond appropriately across the full spectrum of missions.

**National Guard flight medics are often credentialed paramedics with extensive training/experience in critical care transport able to operate across the entire mission profile.

**Regular Army flight medics with EMT-Basic credentials and are not trained to transport post-op or intubated patients, nor are they able to perform advanced airway or resuscitative interventions from the point of injury.

**Medics in RC-S [Regional Command South; based in Kandahar] (101st ABN Div) attended an abridged paramedic program before this most recent deployment. Only 15% of the medics passed this accelerated program and while the remainder are “paramedic trained” they not credentialed as EMT-P’s. They have an expanded Advanced Life Support scope that #2 lacks, but still are not trained in advanced airway management / critical care transport skills.

**Air Force PJ’s (PEDRO) are credentialed paramedics that operate in pairs but lack critical care transport skills and cannot transport ventilator patients. They are allowed to perform Rapid Sequence Intubation and administer blood products but these skills are rarely used or sustained.

**Enroute Critical Care Nurses are able to transport intubated patients from Role II but are not allowed to go to a Battalion Aid-Station or a Shock Trauma Platoon to pick up an intubated patient as these are considered Point of Injury.

**British MERT (Medical Emergency Response Team) is able to bring a full resuscitation team to the Point of Injury and provide aggressive treatment to severely wounded casualties but their response time is sometimes longer than Army MEDEVAC or PEDRO.

**Unit flight surgeons lack the clinical skills, experience and credentials to supervise and train flight medics.

**Discussion: Every GSAB flight surgeon currently deployed to Afghanistan is a PGY1 general medical officer with no additional training in out-of-hospital care, trauma management, medic training, in-flight critical care, or medical oversight of a helicopter EMS system. In most cases, the experienced flight medics have more knowledge of enroute care than the physician supervising them.

**Further, no systems exist that capture adverse outcomes, protocol violations or sub-standard care outside of the individual MEDEVAC unit or GSAB. Lack of patient care documentation in the medical record and trauma databases is the greatest hindrance to developing data needed to drive improvements in MEDEVAC care.

**Conclusions: After more than 9 years of conflict and more than 40 AAR’s recommending the evolution of MEDEVAC to current civilian standards, no institutional change has been made. Continuing the legacy model has resulted and continues to result in documented sub-optimal outcomes and increased deaths among patients transported by helicopter in the current conflict.

Entire document


+12 # Suspicions confirmedMike Barnett 2012-02-23 13:24
I had hoped (well, hope is a crappy word considering the circumstances, but it's the best I've got at my current caffeine level) that something like this memo would surface and show that the Army is indeed aware of this problem, and aware of it from the inside. I'm also disgusted that it turns out I was right. I hope Lt Col Mabrey receives no hassle for this document being leaked.

It's time for a change. The Red Cross MUST be removed. As should all those in the brass who have so far refused to do it.
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-6 # RE: Suspicions confirmedDang 2012-02-23 14:26
Documented AARs point to the challenges faced in the provision of care - and changes made from these are conitnually being made. However, making the HUGE leap from improving training to removing Red Crosses is a just that - a leap of logic. This should not be taken as a defense for the needs exisiting and the time it took to implement them - but, at the end of the day, it all comes down to using the ever-shrinking dollars that Congress doles out to the Army. And, at the end of the day, EVERY dollar can ultimately be tied to saving lives whether it's for better body armor, better armament, or better medic training. LTC Mabry's report has been used to prepare better application of skill sets. PS - the 92% survival rate is NOT a hollow number. I know for a fact it is not.
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+10 # Michael.Yon@gmail.comMichael Yon author 2012-02-23 14:47
Dang -- you say the 92% is not a hollow number; that implies deep inside knowledge and access to any actual study. It implies that you have studied 'the' study.

Show me the money: You either have it, or you don't. Without the study in hand, it's a hollow claim.

Our calls are not just to remove Red Crosses; that's only the most obvious and common sense step. Anyone who defends keeping on the Red Cross will be dismissed as a crackpot or a stooge/mouthpie ce. Arming the helicopters is a separate matter. Removing the red cross is just common horse sense.

MEDEVAC is a very complex issue and with many dirty corners.

What is your stance on removing the red cross?
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+1 # RE: Michael.Yon@gmail.comDang 2012-02-23 15:09
I have supplied the explanatory graph to the members of the RACAC.

As to removing the red crosses I am not opposed to doing so - they are only visible at a closer range than is normally used for targeting (bull's eye is a term everyone loves to use that belies their real visibility from the ground anyway).

Arming them, IMHO, will NOT shorten response time nor add much in the way of measurable improvements. BUT, I do not have "facts" to back that up - only an opinion.

Where will the extra crew members to man the guns come from? Force Structure is a "zero sum gain" - there MUST be a "bill payer" from some other type of unit if DUSTOFF is to "gain" a third crewmember to man the weapons. That's a "Cold Hard Fact" of life when you start to design new unit manning.

AND, when the medic lands, he/she MUST attend to the patient - manning the weapon becomes untenable (unless you have that third crewmember - see above)
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+1 # jlsHoustonJanice Stroud 2012-02-23 17:12
DANG, I hear your beef about the money and yes the ever shrinking dollars congress allocates to the Army are of course the reality Army command has to address. IT is not a solution to take dollars from other life saving units to have funds for that "3rd" crew member manning the gun some of us want to see in our MEDEVACS. However, if we don't change what some of us feel are bad policies simply because of funds available..well that sort of rationale just isn't okay. Pretty much I think John Q Public (and Jane) will take money out of their pockets to fund the health and welfare of our troops. The red crosses are visible and need to be removed and the MEDEVAC birds need to be armed and the money and the policies need to be there to make that happen.
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# MrDJ 2015-09-24 01:28
Removing Red Crosses can only be done if the US opts out of the Geneva Convention Accord/Agreemen ts. Have you ever performed duties as a FM ? Have you ever read the Key West Agreement between the services ?
I served as a FM in the 80's/90's and we were fully able to support a patient from pickup to droopy to include severe trauma patients. We were EMT-B's with additional in ACLS, intubation, ATLS, NALS, PALS and everything in between. We trained in all aspects. Just because the credentials don't exists does not mean we weren't capable. Sounds to me like you need to go make your publishing mark on something else.
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+1 # Every dollar spent? Really?Josh 2012-02-26 03:14
Quoting Dang:
And, at the end of the day, EVERY dollar can ultimately be tied to saving lives whether it's for better body armor, better armament, or better medic training.

Don't make me laugh! I'm in the plans office at my unit, a unit whose entire mission is to train Soldiers, and you would not believe (or maybe you would APPROVE) the loads of Army Mandatory Training tasks we have to stuff into the schedules or require the Soldiers to complete between their regular work and lunch. Warfighting? How about the annual "always keep your work area impeccably secure and never let anyone cyber-bully you or the guy at the next desk might be targeted by a Finnish Phishing Scam that is the DoD's Absolute Number One Priority just now" training, or the training to be alert to possible "insider threats" like rednecks or dissatisfied housewives with gambling issues, (which meanwhile reassures us that Islam has to be twisted Jonesville-wise to pose any plausible threat in CONUS), until it's all we can do to make sure we know what WE are training on before we see our trainee units, a couple of weeks a year, ever....

EVERY dollar? When male Army PT instructors are now having to wear mommy-boobs and preg-Nancy tummies for part of their freakin' "Sensitivity Training"? What lives are saved there?
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+2 # RE: Army Dustoff Medics UnpreparedDan 2012-02-23 14:38
The Army has so much pride in a 92% survival rate (which is an 8% mortality rate). They hold this statistic up and say "this is the lowest rate in wartime ever!"

Well, back in the Civil War, when they were hacking limbs off in a tent with a stick to bite on, the Surgeon General was no-doubt saying "Army medicine is the finest it's ever been, we have a 60% survivability rate, the highest in wartime ever!"
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# RE: RE: Army Dustoff Medics UnpreparedDang 2012-02-23 15:11
Yup - you are right there. Medicine states the outcomes - and they continue to improve - your sarcasm is noted.
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+1 # RE: Army Dustoff Medics UnpreparedDan 2012-02-23 14:43
Also, does Akin and other interested representatives have copies of these Memo's?
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+1 # RE: RE: Army Dustoff Medics UnpreparedArmy Mom 2012-02-24 03:29
I know my Rep. Bilirakis has a copy... at least two copies along with the list of highlighted deficiencies.

Everyone needs to start sending emails and making calls to their Congressional reps. Michael has done the hard work of getting the information and documenting it concisely.
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+1 # RE: Army Dustoff Medics Unprepareda&n 2012-02-23 15:08
Of course you are right Mike as far as you go. But you never get to the bottom line. Why do you never go to the top...This is political because we have a political C&C who has put in place political Generals who will cover for him...be his puppets. We will never get the truth out of them. Do you understand that this C&C could care less about our Military. His every action proves this. We are not fighting this war to win. He refuses to admit who the enemy is. He refuses to do what is needed to defend and secure our country. Do you think he cares about a few, to him expendable, soldiers? With him our enemies are safe and our allies are put in danger and God help our Military for if what he does doesn't make a good sound bite for his reelection it won't get done. If you think you will get the truth out of this C&C and his minions you are just dilusional. And the few who have guts enough to tell the truth are in big trouble....no good deed will go unpunished. These are not times like you are used to dealing with. I know you don't like to be political but want to cover our military and the war from a boots on the ground point of view...but when the problems are more and more becoming political you have to expand your knowledge to see the whole picture. You have exposed the problems...but not the reasons why nothing is going to be done about those problems. This is one serious problem you are trying to get fixed....I've got a list of a hundred more you can start on once this one is covered over by the government by a pile of lies. Thank God for you and our military and those who really care....but we have to change this from the top down...I've lost loved ones...I care too Mike...but we have bigger problems than you seen to understand.
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+2 # RE: Army Dustoff Medics UnpreparedSteve C in MA 2012-02-23 15:27
92% Success rate? I read that as an 8% failure rate. 8 out of every 100 wounded Americans do not get their "Golden Hour" according to the Army's own flawed methods. How many lives could have been saved if the standard was "WHATEVER IT TAKES" rather than "Win some, lose some". We should not accept this kind of fatalistic gambling with the lives of our heroes, sons and daughters. Shame on the Army leadership for allowing politics to kill our solders. Shame.
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+1 # ScobroScobro 2012-02-23 16:06
Quoting Steve C in MA:
92% Success rate? I read that as an 8% failure rate. 8 out of every 100 wounded Americans do not get their "Golden Hour" according to the Army's own flawed methods.

Acutally, the reality having worked in the Army Medical Department, Patient Evacuation Coordination Centers, and with MEDEVAC units, the 8% are almost always non-survivable wounds (GSW to head, major thorasic invasive blast injuries, high percentage burn injuries, etc...) These are injuries that are not survivable even if they happened on the doorstep of a major surgical ward. Get your facts correct before rendering an opinion.
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+2 # Not really 51.4% Potentially Survivablein_awe 2012-02-23 18:42
Take a look at an article authored by the US Army Institute of Surgical Research in the Journal Trauma (July, 2011).

A panel of AMEDD trauma experts in consultation with an Office of Armed Forces Medical Examiners forensic pathologist reviewed 558 Died of Wounds cases from the period October 2001 through June 2009. Their conclusion? 51.4% of DOW wounds were classified as PS (potentially survivable).

As you know, DOW is a classification assigned to wounded troops who survive long enough to be delivered to a Role 2 or higher medical treatment facility.

If you die of your wounds on the battlefield, or while waiting for or being evacuated you are classified as KIA. Had SPC Chazray Clark died just a few minutes earlier, instead of being a DOW he would have been considered KIA. Depending on which survival rate number you are using (the DoD/DMDC has several)the reclassificatio n as KIA would yield an improved DOW number.

There is a documented huge gap in tracking what happens in the post wounding, prehospital phase of a soldier's experience. NATO and some in the AMEDD have highlighted this as a deficiency blocking the essential analysis of policies, practices and procedures affecting MEDEVAC missions.
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+6 # Pedro and PresidentMichael Yon author 2012-02-23 15:28
A&N, I think if you pull out a pencil and some graphing paper and start plotting data points, you'll see a very sharp trend. On the Y axis put the names and ranks of the players, and on the X axis plot the dates of my dispatches wherein those players came onto the field. You'll see that the Y axis is extremely steep and there is only one guy left. But taking this to the President from day one would be faulty. In that case, I should have first written to Bush to ask why he let it fester. There was a chain of command which now is exhausted.

Dang -- you are throwing out straw men which I and others have knocked down months ago. Many of your straw men get knocked flat by reading this dispatch, and if not this one, others such as "Fool's Gold and Troops' Blood": http://www.michaelyon-online.com/pedros.htm

Just say the simple thing: If nothing else, the Army is mistaken to leave on the Red Crosses. If they make no other changes whatsoever (which would be a crime), they should at least remove the Red Crosses. No commander will garner respect by defending the Red Crosses. He will lose credibility the moment he defends the practice. Doesn't matter who he is. He will lose moral credibility, at minimum.
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+1 # RE: Pedro and Presidenta&n 2012-02-25 02:39
No doubt you are right Mike. We've known each other long enough, years now, that I trust your graph...you know I'm just an old horse breaker and I'm not real fond of drawing lines with a pencil. And believe me I go back further than the present C&C. Yes...I know you are right but things just keep popping up...know what I mean? Like my State of Az getting sued by our C&C's big lawyer man for just trying to defend ourselves against invasion across that border...I have my boots on the ground here and know what I'm talking about...like you know about Afghanistan. It's his policy...not some border patrol guy...not some lawyer...that is destroying my State and my life as a matter of fact. And apologizing the the Afghanies...tod ay...I'm not buying that Mike. Nobody ever apologized for 9/11 or killing our soldiers now ...while they kill Christains and burn bibles indiscriminated ly...No...I'm sick of our C&C apologizing for me when I'm not sorry not do I think we should be. That's policy...nor do I think the terrorist at Ft. Hood was a workplace incident...That 's polacy and I guess I live this, especially when my friends are killed in this war and maybe I feel better going off a little...Horse breakers are like that you know. And I am a sort of bottom line kind of person...maybe that's why I trace it back...my line goes back to the one where the buck stops...or anyway it used to stop. Thanks, Mike, for caring enough to set me straight...I was wrong before once...as I recall. Nobody is perfect but that being said...a&n do appreciate what you are doing and say...take the dang crosses off the helicopters and arm them. Is it true...KIA means they didn't evern survive long enough to make it on a helicopter alive? That's important to me. It means maybe he didn't suffe long...if you get my drift, Mike. Thanks.
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+2 # You are awesome A&NMichael Yon author 2012-02-25 12:05
And I don't want to argue with someone who can break horses. :)
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# RE: You are awesome A&Na&n 2012-02-25 21:24
Horse breakers are tough okay.....and a good stable boy is impossible to find.
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+1 # t looks like an aiming pointDane 2012-02-23 15:47
I just came from the WarOnTerror website.
They have a news article entitled " Devil Ray dustoff teach patient extraction procedures" if you look at the red cross on the helicopter shown in the picture it sure looks to me like theres three bullet holes inside the red paint of the cross on the nose of heli. What a perfect target for the enemy to aim at.
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+1 # Bullet holes?Scobro 2012-02-23 16:17
Try again. They are screws that are holding a mounting plate for a piece of avionics in the nose of the aircraft. The nose of aircraft hold the avionics (radios for dummies). If those were bullet holes, the aircraft would be in a hanger being repaired.
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+2 # LTC Mabry is The ManHeywood Jablomi 2012-02-23 15:50
Beautiful memo.

Too bad that it has been ignored.
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+4 # COMPARATIVE SKILL LEVELSRon Rogers 2012-02-23 16:28
In "Thoughts From A Dustoff Pilot" the skill level disparities were already pointed out/ Here is the PJ POI:
Pararescue EMT-Paramedic Training, Kirtland Air Force Base, New Mexico - 22 weeks

This course teaches how to manage trauma patients prior to evacuation and provide emergency medical treatment. Phase I is 4 weeks of emergency medical technician basic (EMT-B) training. Phase II lasts 20 weeks and provides instruction in minor field surgery, pharmacology, combat trauma management, advanced airway management and military evacuation procedures. The airmen are then sent to Tucson, Arizona for hands-on medical training. Trainees work along side paramedics with the Tucson Fire Department as well as local hospitals. Graduates of the course are awarded National Registry of Emergency Medical Technicians-Par amedic (NREMT-P) certification.

Army Flight Medic training is a 4 week course for existing Army medics. It is similar to portions of the AF course.

All Army medical skill competencies are at the EMT-Intermediat e / Paramedic level. All tasks encompass skill levels 1, 2, 3, and 4 soldiers. [CONTRADICTED ABOVE!]

"HN" wrote: "- Statistics absolutely prove that Reserve and NG units have better patient outcomes than our Active Duty. I completely agree. I was a part of that research and saw it first hand. The Army has now started to fly ICU/Trauma Nurses with DUSTOFF until the Flight Medic training is up to par. Even after the Army Flight Medic reaches the EMT-P standard, the Nurses will continue to fly. In the same way that the PJ team often flies with a Flight Surgeon when they fly CASEVAC on PEDRO."

So it is clear that Army flight medic training has long been deficient and the proof is twofold. The Army is changing their training this Spring) to come closer to the PJ standard and they are augmenting the Army flight crews with more highly trained nurses.
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+1 # EMT-B vs Paramedic survival dataJeremy 2012-02-23 17:29
You were part of the research which concluded that found NG Civilian trained EMT-P's had a 66% higher survival rate than active duty EMT-B flight medics? Is this the research you refer to?

If so I would really like to get my hands on this paper/document. I've done pretty extensive searching of different medical literature databases and have been unable to find this document.

I ask for this not as a skeptic. I believe there is a significant difference in survival when comparing patients treated by EMT-B vs EMT-P. I want to use the article as support for needed changes at a faster rate on a lower level.

This paper would prove very beneficial. If you could post a link or give directions to it here that would be greatly appreciated.
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+1 # IT WAS "HN"Ron Rogers 2012-02-23 19:44
who was involved in the study. I believe that we have at least two people here who are directly involved in studying MEDEVAC data.

He or she said that both the Guard and Reserve had higher success rates. It makes perfect sense if you know who serves in these Guard and Reserve units. They are often people who are medical professionals in civilian life and/or supply MAST support to areas in our country.

Some are dedicated individuals who go outside the Army to obtain training and certifications at higher levels than their MOS requires. Often, this is at their own expense and on their own time. Owing to their selflessness, we can expect a higher level of care from many Reservists and Guardsmen.

I arranged for our SF medics to spend time in the ERs of local hospitals. Nothing beats hands-on experience. You can't restrict yourself to only what the Army offers when you know that the job requires more.

Hopefully "HN" or someone else will contact you.
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+4 # RE: Army Dustoff Medics UnpreparedRon 2012-02-23 16:43
Michael, I have passed on this info and the Memorandum to a doc here in Houston that was a driving force behind Houston Life Flight program and a driver behind EMS here in Texas and beyond... Dr Red Duke is a force that can add weight to this discussion from the civilian side. Great man and a better Doc...
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+1 # HE COULD HELPRon Rogers 2012-02-23 19:31
Dr. "Red" Duke was the subject of a "60 Minutes" piece and had one of the first medical reality shows.

He could be an eloquent spokesman on this subject and much of the Army medical training takes place in Texas.
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# Mr.Serge 2012-02-23 16:47
Considering all the proposals, their implementation would cause additional expenditures throughout as well as increased bureaucracy at all levels of command. The most likely outcome, if any, could be evaluation of any possible changes in Patient Evacuation Coordination Cell (PECC) decision-making processes and policies. Even than, MEDEVAC asset allocation will always be viewed from the point of short term economic and battle efficiency. Do not forget that soldiers are just another asset like helicopters and other materiel. Every one of them has his/her value and nobody is going to pay a bigger sum of money in order to rescue a smaller one, it is simply absurd. The US ARMY single soldier basic military training and serving, including healthcare benefits, tax breaks, life-insurance and disability insurance, wear-and-tear of equipment, ammunition, moral and transportation costs, on average does not exceed $400,000. According to "United States Department of Defense Fiscal Year 2012 Budget Request: Program Acquisition Costs by Weapon System", the US ARMY UH-60 Black Hawk helicopter unit cost is $21.3 million (avg. procurement, 2012). Its average operating cost, by the way, is 2,199 per flight hour (Head 166 — GOVERNMENT FLYING SERVICE). Also taking into account helicopter's scheduled and unscheduled maintenance and operating costs makes it absolutely clear that from sheer economic point of view it makes no sense administering any changes to the system which might lead to an unfavorable leverage against a more costly asset as a result of changed MEDEVAC policies. The MEDEVAC system currently in place is truly a success story simply because it envisages and implements the best possible correlation between current operational effectiveness of MEDEVAC assets and economic efficiency of Combined Joint Task Force as part of the International Security Assistance Force in Afghanistan.
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+4 # WHAT PLANET ARE YOU FROM?Ron Rogers 2012-02-23 19:28
This is not an MBA case study problem. We do not weigh a soldier's life against the cost of a helicopter or other system. You posit, without a single supporting fact, that some changes might drive costs up. We don't know that. Put your calculator and eye shade away.

This is about delivering a standard of care and saving lives. If, down the road that means replacing slick Blackhawks with Pave Low helicopters, so be it. We can sacrifice some other system to be able to fulfill our solemn obligation to our troops. One thing is true. This is a case of priorities and no American should put anything above troop care both in war and after it. I do recall, that beginning in WWII, before we began bringing back all our wounded as fast as possible, we did justify going to extraordinary lengths to rescue downed pilots because it used to take time and $250,000 to train them.

Now we do it because few pilots and soldiers wish to sign up for one-way trips.

"Serge" I sincerely hope that you do not hold any responsible position in an organization which is directly involved in this subject matter. Your type of thinking is alien to American values.
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-3 # Mr.Serge 2012-02-23 16:58
MEDEVAC asset allocation policies have been viewed from economic vs. operating efficiency point of view. The US ARMY single soldier basic military training and serving, including healthcare benefits, tax breaks, life-insurance and disability insurance, wear-and-tear of equipment, ammunition, moral and transportation costs, on average does not exceed $400,000. According to "United States Department of Defense Fiscal Year 2012 Budget Request: Program Acquisition Costs by Weapon System", the US ARMY UH-60 Black Hawk helicopter unit cost is $21.3 million (avg. procurement, 2012). You would never become a general in the eyes of a responsible financier if you proposed to rescue a smaller asset by losing a bigger asset.
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+5 # DrDavid Prentice 2012-02-23 17:03
I was an Army 91B-F flight medic from 1989 to my eventual ETS from the National Guard in 1997 (I think that is a 68W-F in the current MOS structure). I served in the 1297th Med Det (AA) and in the 1085th Med Co (AA). Today's report is no bullshit and echoes my own experiences and frustrations during that time. It makes me sad to think that nothing has changed. The standard of training is "EMT-B", but at that time many medics did not bother to attain or maintain the National Registry standard of certification. Attaining or maintaining any HIGHER level of National Registry certification was discouraged by our supervising physicians, discouraged by our chain of command, and something that could only be done on your own time by participating with a volunteer ambulance service (to obtain the required physician supervision) and own dollar (for the training). We did, in the flurry of activity around Desert Storm, manage to get support and approval for ACLS and ATLS courses which are normally only open to EMT-P level providers (or higher) but only those who independantly maintained an EMT-P (or higher, we did have a RN as an E6 medic) were allowed to carry those certifications. The doctrine was "grab and run", "patch and pray", with the expectation that casualties would have minimal transit time to a FOB/BAS for higher care. We were functioning with a Korean War model of operations, using Vietnam War technology, neither of which made any sense to experienced ambulance crew medics with civilian EMS experience. I cannot be prouder of the medics, crew chiefs, and pilots that I served with. I know that we all put forth our best efforts at all times. It saddens me to realize that the potential that these aircrews represent has still never been realized in the Army except for in one or two National Guard MEDEVAC units which have a civilian MAST mission stateside to maintain.
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# civilian medics betterpeter 2012-02-23 18:19
Hi. After reading all of the above, sad to say, I think our civilian medics are better qualified. I work in emergency medicine. A number of my medics are 20 something females. They are now doing both RSI, and I0's in the field. They are really not all the difficult to do, but do require 8 to 16 hours of training. I think the Army is woefully behind the times. I think the Army Brass and politicians are also stuck in the 50's on this issue!
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+1 # RE: civilian medics betterRyan 2012-02-24 05:32
Being able to do IO's and RSI in the field is a monkey skill, the real medicine is being able to identify when it is and isn't appropriate.
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-4 # Geneva Convention addendumDang 2012-02-23 18:40
We constantly hear about the GC being used as an "excuse" - Consider if you will that the GC is an "international treaty" or "international agreement" that the United States is a signatory to.

Consider if you will that the standing defense forces follow the orders of the POTUS and Congress in terms of fighting our nation's wars.

If we want that GC guidelines changed, then IMHO the "buck stops" with Congress and the Commander in Chief.

To my knowledge nobody above the pay grade of the Chairman of the JCS has issued an order/directive allowing the Armed Services to NOT follow the GC.

Once that gets altered, I believe all manner of changes could be effected possibly to effect shorter response times, etc.

However, that's not happened - nor is any effort being taken to get Congressman Akin to take that on as a mission - instead, the "Monday morning quarterbacking" continues.

Yes, we need better training - no doubt - We've been fighting that war since Moses was an PFC.
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+3 # GC Guidelinesin_awe 2012-02-23 18:59
Understand that the GC explicitly release signatories from their obligations under the GC when combating a non-signatory foe that has been given a reasonable time after commencement of hostilities to agree to the terms of the GC and begin implementing them. If they fail to do so, then the signatory power may at their discretion elect to uphold whatever provisions they wish to, but are under no obligation under the treaty to do so.

The International Red Cross site on the GC has a nice commentary just in this point at paragraph 3 item 2 at http://www.icrc.org/ihl.nsf/COM/365-570005?OpenDocument
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+3 # ILLPGICAL AND UNINFORMEDRon Rogers 2012-02-23 19:06
If you had been reading this blog for an length of time, you would know that the Air Force, Marine, and British helicopters fly without red crosses. So I guess that they "are not following the GC." Last time I looked they reported to the same Chairman, SECDEF, President, and Congress as the Army. Apparently, they did not need permission. The Army proudly hides behind its Title 10 authority and responsibility.

Your dismissal of the quality of training has not been around since ..... The Army has been bragging about Title 10 and the quality of their in-flight medics and it has been a lie. The individuals are great, but they have not been trained properly. Therefore,the wait for the adequate treatment of a Class A casualty is not merely the time until the chopper arrives. It is the time it takes to get him to a medical facility because the Army in-flight medic is limited by his/her training.

Monday morning quarterbacking is long overdue. Until Michael publicized this issue, no one was talking openly about this training issue and our troops have not been receiving "the best possible medical care" as so many generals have assured us. They are either ignorant or have been lying.
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+1 # Gains In Quality of MedeVac Service FailingFThomas 2012-02-23 18:45
This report shows how miniscule the training requirements have improved over the past 40 years. I believe that there are MedeVac Crews within the system that have taken it upon themselves to improve their training and thus their effectiveness on the battlefield at an individual and/or unit level. Overall, the MedeVac System suffers from 100 years of tradition unhampered by progress. This does not bode well for our troops on the front line. They are not only NOT getting to higher levels of care in an expeditious manner, but they are denied the highest level of care during transport - if and when it arrives. Combining both of these issues is a recipe for disaster and the continued unnecessary loss of life as a direct result of the poor use of assets dedicated to prevent that from happening. This entire issue continues to raise more and more troubling questions than supplying us with answers and solutions.
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# Not entirely accurateRobert 2012-02-23 19:28
I read many of your posts with great interest. Particularly the most recent ones regarding medevac. However, some of the "facts" above are not accurate. For instance, I know for a fact that many of the doctors are not PGY1s, but in fact board certified physcians. Additionally, the flight nurses are allowed and have been picking up POI patients, especially ones who are coming from an FST or BAS and are critically ill. In fact, every critical care patient that I am aware of are being transported by a PA, critical care nurse, or physician in addition to the flight medics. Finally, there is in fact, one set of medical flight protocols that has been adopted Army wide in Oct 2011. It can be found on the aviation school's website.

I agree that the system that trains the medics is inadequate. That has been an issue for some time that has been identified. Dr. Mabry is not the first to point this out. In fact, there was a very detailed article published by the AMEDD detailing this very fact and oulining how to fix the problem. Training the flight medics to the EMT-P level is not that difficult. Maintaining them at that level is far more challenging as the ongoing commitment of time, money, and resources is enormous.

I agree that there are many things to fix with the medevac system. The undertraining of the flight medics is a recognized problem that is being addressed the best way possible in the short term while the long term solutions is being worked out. Why it has taken the Army a decade to start to work out the problem is up to people that make a lot more than me.
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+3 # Accurate when issuedin_awe 2012-02-23 22:06
Please note that this was a report on a span of duty in Afghanistan in late 2010/early 2011. At that time the statements reflected the situation.

As personnel is rotated in and out, the attributes of the individuals and the group as a whole dynamically change. But how is it possible that what was reported was an acceptable situation? How did that pass muster?

There are a number of articles that state that the ECCN situation is still bad. And some readers with current knowledge hint that TACEVAC with Afghanistan has continuing issues.

I have found AMEDD articles dating back to 1999 which clearly state that the training of combat and flight medics should be upgraded. The same basic argument was published again and again in the AMEDD Journal throughout the past decade. So, thirteen years to modify a curriculum owned by the AMEDD! Since 2005 AMEDD has had the responsibility of providing training for medics of all services at a rate of 20,000 per year. So there wre 6yr x 20,000 medics being trained at less than desired/recomme nded levels of skills. Why? Who up the chain of command was aware of this? Did this ever get to the JCS? Secretary Gates? Secretary Panetta? If not, why not?!

The revised AMEDD training regimen has just started but is limited to incoming new medic candidates. Why not include those existing flight medics scheduled to be deployed starting in xx months? Wouldn't that make sense??
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+1 # Medevac dataARNG Flight Medic 2012-02-24 04:53
Actually this study was published from the data from our tour in Late 2008-2009, and was absolutely correct for that time period and for the most part I am sure is still correct. We were the first Medevac company to record our Patient Care Record data, and proved once and for all that paramedic level training was needed for flight medics.
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+1 # MedevacARNG Flight Medic 2012-02-24 04:59
Additionally the reason that Nurses/PA's and Docs are going on flights now is because all the Paramedics left with the National Guard. Those protocols at the schoolhouse are basically the ones we were using in our tour. Most Army Docs are not prehospital specialists so during our tour we were teaching them how to do EMS (Emergency Medical Services). That's the benefit of bringing National Guard where most of your medics are Career Civilian Firefighter Paramedics with years of real world prehospital experience.
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# RE: Accurate when issuedRobert 2012-02-24 19:01
It seems by inaccurate, I really meant out of date. I saw the date at the top of the document was February 2011 and for some reason thought that it was from this year. The things I called inaccurate where actually just out of date. I suppose that shows that there have been some things that have been addressed since the memo was first released. There is certainly a long way to go on the training of flight medics, but at least there's some movement.
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+1 # Time for changeGrenadier 2012-02-24 04:50
This and previous discussions regarding MEDEVAC issues is very revealing. Sadly, Army "policy" on Red Cross markings and training of in-flight medical personnel is outdated and appears to killing our Soldiers. The cost/benefit "MBA"argument is disgusting in an organization that prides itself in "leaving no man behind." Are we leaving men behind if our training is outdated? Is it possible to eliminate the full color red cross markings on our evac birds? How about subdued markings? Why defend the indefensible? It is time for change.
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# What?!?!Scott K 2012-02-25 00:05
OMG!!! EMT-B's?!?! HOLY CRAP!!!
Seriously, this is boggling. Stateside "medics" (EMT-P's) have been convinced for years that the Army dudes have the $#!^! We've been convinced that the birds were outfitted with portable vents, sinthetic volume expanders, all the cool stuff, and that the Army "medics" were closer to MD's than EMT's.

I did 16 years on private ambulances, and - from what I read above - *our* "B's" (basics) were trained better! Hell, *I* could train them up on advanced airways, IV, and vent! Oh, wait, maybe those 10 pound portable vents would be too heavy!

And some bonehead above is quoting about PECC?! Come on, Man! This is LIVES, here, not bureaucracy! 2 weeks, that's what I'd need to train 'em! And they'd DEFINITELY pass at better than 15%!

OMG, I'm seriously nauseous thinking about this.

Michael, keep on 'em. I think you got 'em by the short and curly's! Contact the staff at JEMS - Journal of Emergency Medical Services, about training levels, accelerated programs, and current practice. We got some awesome stuff from the military R&D guys the last few years, but it's now apparent it wasn't from Army MEDEVAC.
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# RE: What?!?!Kurt Olney 2012-02-25 06:39
Scott, I certainly hope your offer is taken up. I too am discouraged that our Dust Offs are delayed and vulnerable and that our wounded soldiers get less than the best emergency treatment. 92% is a meaningless percentage. 8% is a tragic percentage.
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# Ret CW4 AVNflytiger 2012-02-26 16:18
The Warrior Generals that I think would act are retired ( forced to Retired in McCrystals Case)........Ex pect little or no change of policy as the current crop of "Leaders" at the TOP do not have the common sense to order corrections to the policys in place. As the drawdown and lack of funds really hit it will only get worse.Dustoff should go with or without escort...ask the Vietnam Guy's about that!
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# Medics not MedevacJustin Avery 2012-02-27 13:57
I am an Aeromedical Evacuation officer in the Army and have been deployed four times to the Iraq theater in Medevac units. There are some very good points made in all the discussions about this article. I just like to clarify one thing. It is not the Medevac system that is failing, but the training the 68W receives. Medevac and the capability it brings to the fight is unparalleled and no other service does it better than the Army. The quality of enroute care provided by the 68W in the helicopter is limited, for many reasons. Either equipment, the situation, the type of injuries and / or training. There is no absolute best solution to providing the best enroute care. There are always exceptions to every case and anyone can disprove or claim something is wrong after enough research. The point being, don't criticize the Medevac system when the problem is the training and qualifications of the 68W. The AMEDD has recognized this capability gap and is working to fix it, but as with all things in the military, things take time. There is no value that can be placed on human life and if you talk with any Medevac crew that has performed in combat, they will agree that everything possible is done in order to save a life and the Medevac system should not be criticized as it is in the article.
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-1 # Medics Not Medevac?Ron Rogers 2012-02-27 14:27
If you can read the entire thread on this subject and conclude that the MEDEVAC system in Afghanistan is not broken, then you and other officers like you are the problem. Of course 68W training is inadequate and the AMEDD has been siting on this for 10 years. The revision of the POI is easy and you have not done it. Just use the Air Force POI. The existing instruction is already similar to the first 4 weeks of the PJ's training in terms of subject matter. AMEDD's intransigence is inexcusable.

I refuse to go back over the Afghan/ISAF bureaucracy and risk aversion wgich delays our MEDEVAC responses. The other issue is the stupidity of clinging to red crosses and unarmed helicopters when we have been fighting nations and enemies which have never signed the GC and now are fighting folks who can't even read the treaty. The inability of AMEDD to pull its head out of its 4th point of contact is astounding. If you read the Treaty, the wording hasn't been relevant to our form of MEDEVAC since we started to use helicopters in the Korean War. Even in WWII, the red cross meant nothing most of the time. It certainly did not protect our medics and corpsmen.

You should be ashamed to don the uniform in the morning.
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# Medic Trainingepador 2012-02-28 06:21
The last I spent any time on military medicine for the battlefield, I sat through one too many conferences/e-m ail threads where SOF Medic Handbook 2 and its predecessors were minced to death 5 years ago. The problem predates the current BS and is not just an AMEDD problem, but a problem of coordinating medical care/planning/t raining across five and a half services.

We have all these wonderful parts and pieces, yet as they are still all developed and maintained within their separate services, they don't fit together. The Army system is designed to operate only with Army parts - I see the other services work harder to fit together, but just as in the SOF Medic process, AMEDD is one big sabot in the machine.
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# Crosses & Gubs not the problemMMike 2012-02-27 21:11
First, Red Crosses and no guns is not the problem; there are 99 other things that are requyired to launch a MEDEVAC. There is not one stitch of truth in saying that just because MEDEVAC aircraft are marked with Red Crosses and do not have guns is the reason that it takes extra time to launch on a mission.

That "stupidity" that you refer to may not protect MEDEVAC aircraft, but if you remove them, that aircraft will be used to haul mail and ammo, not casualities. Plus, add guns, ammo, and gunners, you will add time and weight to the aircraft that will reduce the amount of patients and equipment that can be carried to safety.

Plus, Ron, if you had an idea what it takes to actually change things in terms of training development you would keep your thoughts on that to yourself.
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# Crosses & Gubs not the problemRon Rogers 2012-02-28 00:04
They are not the main problem in my opinion. It is the 99 other things which concern me. We have constructed a ridiculous hierarchical bureaucracy which involves the judgement of people not competent to second-guess the LTC BN CDR on the LZ or the BDE CDR "battlespace owner." Michael walked into a PEEC to find a medic who knew nothing about MEDEVAC operations nor was he competent to review the tactical situation. AND, there is no reason to have to wake up as general to make a launch decision. That's both ridiculous and sad. Read what the Battle NCO wrote describing his BDE operation. And he is not the only Battle NCO to comment in the same vein. Then read what our gunship, MEDEVAC, and PEDRO pilots have said. It is the bureaucracy's aversion to risk and decision-making that creates the need to take away the excuse that no gunships are available or to wait till one spools-up and calibrates its weapon's system as happened in the case that started this revelatory series. Let's not go with my opinion sitting here in CONUS with dated RVN experience, let's go with the the experience of the NCOs and pilots who fight the problem daily.

If the Army cannot expect an Aviation BDE CDR to follow orders and keep his hands off MEDEVAC assets without red crosses then the Army is more screwed-up than it now appears. Are we plagued with renegade commanders? However, you make an interesting point. Without the red crosses, an outward-bound dedicated MEDEVAC chopper could carry water and ammo on board IF and only if those supplies were at the launch site. Let's think a little outside the box.

On training issues, I guess you don't want to count working on the no defunct Army Training Board (TRADOC)and rewriting the Army Infantry School Advanced Course POI as relevant. Besides, I recommended copying the Air Force lesson plans. How hard is that? AMEDD has had 10 years to get off its fat ass! This will create some bumps in the pipeline - tough, the troops come first.
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# Launch ApprovalAvery 2012-02-28 00:40
You bring up a good point. Before 2005, Medevac units were self sufficient stand alone units that reported to a MAJ as the Commander and that commander could approve almost any mission that came down. Launch times from notification to wheels up was averaging 6-7 minutes. With Army transformation and Medevac moving under the command and control of Aviation units, things became more complicated, regardless of what the Medevac commanders told the BN and BDE Commanders. It's not a perfect system, but it is the one we operate under now. There are many units who have cracked the code and achieve the quick launch times and those lessons have been captured and shared, but in the end, it is up to that commander who makes the decisions regarding Medevac. Your personal opinions about a system you appear to have little to no knowledge about are disturbing and before you bash it, you need to understand it first. I'm not saying the system is the best and I personally would prefer to go back to the old days of Medevac being a stand alone unit and flying single ship in order to get to the patients faster. I have experienced it both ways and they have both worked. Again, there is always room for improvement and the first step in working towards a better system is understanding the full dynamics of the problem and possibly providing better solutions. But understand one thing, Army Medevac is the best in the world and without it, your casualty survival rate would be reversed, 92% dead.
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# Launch ApprovalRon Rogers 2012-02-28 01:21
I appreciate your insights and they agree with this long thread. My understanding of the launch approval process comes from this thread and the comments of pilots and Battle NCOs and one Battle Captain. You are right, I do not understand a process that can rise above brigade and involve ISAF and generals and unqualified personnel at a PEEC. If a BN Commander is standing on an LZ and says that it is not hot, who the hell has information better than that?

I profoundly respect the personnel and performance of the MEDEVAC Company, but you are wrong; our system is not the best. That's like saying if you get the patient to a medical facility within the Golden Hour - that is good enough. Some casualties do not have that much time. Active Component flight medics are inadequately trained. Ask yourself, why do Guard and Reserve MEDEVAC units have higher survivability rates? The answer is in the AMEDD LTC's Memorandum For Record and in the Guardsman's explanation of the training that they themselves pay for and the two Guard units which have a MAST role.

With all due respect, PEDRO is the best in the world unless you prefer the British system which delivers the hospital to the patient. And, I have no idea what the Marine's data would show, but a Navy Corpsman's training is way superior to today's Army Flight Medic. If the Army in-flight care was the best in the world, we wouldn't be putting nurses, PAs, and doctors on flights now. Pride in unit is one thing, blindness is another. In the LTC's MFR, we learn that patient outcomes aren't as good as they could be and that 92% only means that they are alive on the table when you deliver them. He suggests that if they had better en route care, the outcomes would be better. We have to take the data further. This ain't Vietnam (thank God) and we should not be so overwhelmed with casualties that we can track and record and analyze outcome at each stage. I do thank you for your dedication.
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-1 # Clearly confusedMMike 2012-02-28 03:02
Ron, you are clearly confused on several points:
1. the reserve MEDEVAC companies were JUST stood up and mostly still un-manned...the y do not even really have survival rates yet.
2. The Navy sends corpsman to the flight medic course.
3. PEDROS are so incredibly overrated it is not funny; they might be able to transport a patient if they can take off without hitting something.
4. All critical care transport standards include a doc, nurse or PA, since any sole provider would be incapable of providing "the best" care

Finally, how about we focus on the morons setting IEDs and suicide bombs, that require MEDEVACs to happen in the first place.
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# RE: Clearly confusedKurt Olney 2012-02-28 04:13

I really appreciate this discussion. You will not find it in the main stream media. ----- No one questions the bravery, dedication of our military pilots and crewmen. As a Vietnam Veteran and American, I am concerned about about the lives and well being of each of our soldiers.----- Michael Yon's story brought up a lot questions about crosses on the dust-offs, response time, etc. And you can see from the responses that there is a divergent of opinions. I wish forums like this existed for those of use who served in Vietnam. I always hope the right decisions are made by our commanders for our soldiers who "are in the fight."
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# Tom Rick's Best Defense BlogRon Rogers 2012-02-28 05:13
You will find many Vietnam vets of all ranks commenting on current events and Vietnam at:

He told me that he is a good friend and admirer of Michael
Yon's work.
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# Confused, Not ClearRon Rogers 2012-02-28 05:08
1. My bad, LTC Mabry only cited a study of Guard units and the only relevant comment was by a member of one of the Guard units who explained their extra training.
"A recent study that compared critical care trained flight paramedics from a US Army National Guard air ambulance unit versus the conventional MEDEVAC systems operating in OEF showed a 66% reduction in death at 48 hours post-injury in severely injured patients."
2. You ignored my point. A Corpsman is like a SOF medic and is trained to do stitching, etc. They are as well-trained as AF PJ's who approximate SOF medics.
3. That's very silly and detracts from the validity of anything that you say. A friend of mine is the SEAL medic of the year and he admires PJs who occasionally accompany SOF units. The highly sophisticated avionics in AF and SOF Pave Low helicopters assist the pilots in avoiding somethings.
4. The Army acknowledges your point and puts additional medical professionals on flights to augment the flight medic for critical patients. This has been covered on this blog. PEDRO flights carry 2 to 3 PJs to perform medical care. Not sure about the Marines, but the care is provided by a least one Navy Corpsman.

We focus on what we can improve in our operations.
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# Service Specific RequirementsAvery 2012-02-28 11:53
Ron, you bring up very good points about the training each service provides to their medics. There is a reason they are different than what Army medics receive. The Navy or Marines don't have a dedicated Medevac system and rely on opportunity lift. They also don't have the same volume of service members that may have to be treated. They can afford to spend more time on training to produce fewer, highly qualified Corpsman. The Air Force PJ is designed for a very specific role, recovering downed pilots. This also explains why their helos are filled with tons of technology and guns, but this limits the number of patients they can carry to two. Also, if there is anything that the Air Force is doing in regards to Medevac operations today is because they learned it from the Army in 2003-2005, trust me, I know because they followed my Medevac unit during that time and wanted to learn about our systems and methods. Now, all that being said, the better qualified a medic is, the better the care they can provide and I agree we should spend more time training our medics, but the reality is we need a lot of them and the Army is so large that it requires them to be complete with training faster. Does it justify their apparent lack of skill, no, but it is the current situation. To give you an example, the Army pushes approximately 2000 medics through training every year and at the peak of the Iraq war it was close to 3000. I know because I was commanding a training unit required to push them through. Point being, each service as a specific requirement for medics and each service adapts their training and equipment as such to accomplish the service specific mission.
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# Specific Service RequirementsRom Rogers 2012-02-29 03:07
I take your point and I understand. However, AMEDD does say that the course will be changed this Spring. But let's assume it isn't. Then we (the United States) need to do what the medical community calls in-service training. First, Iraq is over. Second, unless we are again grossly undermanned, the workload just isn't that grea. Let the Nurses, PAs, and doctors provide training. If the nurses and PAs are now on standby with the choppers, let them hold classes on the specific tasks that could make a difference in their experience in-countr. TRADOC used to use the concept of performance-ori ented training. I'm sure that some generals have changed that term 17 times since I got ou (1984.) Basically, the individual soldier studies and task and then physically practices it until he or she can perform it perfectly. As a poor example, but one I understand; breakdown and reassemble your rifle blindfolded in "x" amount of time. So, insert an IV, back-flush it and hook it up in "x" amount of time. Check that it's flowing. If they carry equipment to control and pump the IV; properly program it for the particular fluid being infused.

Forgive me,Vietnam have seen what mass casualties can mean. I would think that we are over-manned at our medical facilities with plenty of downtime from emergencies. Thank God, we just do not have that many casualties compared to other wars.

Lastly, please go back on this blog to where some MEDEVAC pilots, PEDRO pilots, and medics refute the concept of how many casualties can be carried in this war. They suggest that one medic would be stretched to handle 2 patients of equal severity. I seem to recall that the PJs can squeeze two patients in. So I defer all such issues to them. I take your point about guns and medical gear and different missions orientation; but thanks to your unit and others PEDRO is highly competent in this arena and we should be happy to have them. Not many downed pilots these days.
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# Who is we?MMike 2012-02-28 19:39
Ron, When you say "We focus on what we can improve...", what are YOU doing to improve Medical Evacuation?
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# WeRom Rogers 2012-02-29 03:20
We be citizens and voters now. Some of us served in the Army in other wars at other times. Michael asked us to write certain Congressmen as well as our own and to write the JCS. I did so. This resulted in a conversation with a very interesting JCS LTC. I cannot sit here and do anything about IEDs or bloated ISAF bureaucracies. On other forums and in private communications with SOF personnel and Afghan Hands, I try to share any experience that I have that might be relevant. Some of them think it helps.

The other thing that I do very aggressively is to point out the reasons why we cannot succeed in Afghanistan and urge that we get out ASAP. That would remove the requirement for MEDEVAC for conventional forces. What are you doing, if I might inquire?
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# looks good on paperLonestar doc 2014-08-15 04:42
In the 3 1/2yrs. I served as a Flt. Medic, approx. 200 lives were saved and your 8% probably had something to do with expectant cardiac or traumatic brain injury. I suggest going on a mast mission and seeing 1st hand how the crews not only ensure the patient is brought to advanced care swiftly, but also ensure all aircraft safety procedures are constantly maintained. Once trained rl-1 and mission ready, the real measure of intestinal fortitude is brought to light. Some cant handle traumatic amputaions and keep a patient calm, but we weed those few out before they get a life in their hands. Every flight crew continually improves reaction times and can anticipate each others needs. Selflessness and dedication to the preservation of life is the job and they proudly serve our country. Don't criticize until you are bleeding out and that "poorly" trained flight medic can identify your injury in seconds and bring you home. I regret not serving longer, but going back to Iraq as a contractor paid for college much sooner than my downsizing pay could. OK...I am done. Just frustrated doing research online on my old medical and Infantry units and got slapped in the face when I read your messages.
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# Looks Goodin_awe 2014-08-17 15:21
Lonestar - thank you for your service and commitment to providing the best care possible to the wounded.

I understand your frustration and anger about some comments in this thread. But I believe that the passion behind every comment reflects a genuine desire to make sure that the MEDEVAC >>system
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# Medevac is a PlatformAvery 2012-02-29 11:38
I think everyone can agree that the training of the flight medic needs to be better and realistically, they can really only provide quality enroute care to two patients. This was a major limiting factor I experienced and we sometimes sent more than one medic and employed the use of enroute care nurses. So yes, the current system is flawed in that respect and steps are being taken to make it easier for the medic to have physical access to patients while in flight. The existing litter system on the UH60 is inadequate and doesn't allow for access to all patients. That being said, the platform of Medevac is designed to get the patient from A to B quickly, not necessarily provide better medical care than they received at the point of injury. An example of this is a mass casualty event I experienced in Iraq of 06 when we had 24 urgent patients. We launched 4 helicopters and loaded each one with 6 or more patients, the max capability of the UH60. The entire event lasted approximately 1 hour and all 24 patients survived. The amount of enroute care the medic provided was almost nothing, but the thing that saved the lives was the fact that Medevac was used to transport the patients. That is what I mean by Medevac being the best in the world. The Army has 13 active duty Medevac units and many other Guard units that are dedicated to the mission. There is no other force in the world that has this dedicated capability and my whole point from the beginning is without this, the survival rate would be much lower. Some decisions by senior leaders and politicians have made it less efficient and less capable than in the past and we need to work toward making it better. The PEDROS may the example to follow, who knows. The one thing I do know is all DUSTOFF units and people within those units carry with them the tradition that was born from Vietnam and the bottom line is doing whatever is necessary to save a life.
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# Excuse me while I step onto my soapboxARNG Flight Medic 2012-02-29 18:18
Okay, the Pedro and PJ lovefest is really starting to get out of hand. My personal experience with Pedro and the PJ's was not positive overseas they crashed multiple helicopters and provided poor patient care during my time downrange. I am sure there are great folks in the organization but I didn't experience it. Yes they are trained above the current levels of army flight medics, but it is my understanding that they removed the paramedic requirement from their training program and now just do "equivalent" training. Ask any paramedic, the difference between a brand new paramedic and an experienced one is night and day. Both SOF and PJ's send folks to paramedic level training but it is usually minus the clinical emergency room rotations and the civilian ambulance field internship which is where the real learning happens. Also after training up on medicine most of these folks end up spending most of the rest of their careers on shoot training, rappelling, diving, halo, and everything else besides medicine. Medicine is a perishable skill - do you want a guy that learned it once but has no requirement to keep up to date treating your soldier. I can teach a monkey to start IV's but you need a skilled and quick thinking professional to assess the situation determine the severity of injury and use their understanding of the pathophysiology of the human body to determine what to expect next. You also need someone who is in their element in the chaos of the prehospital helicopter environment and is hands on and makes things happen (which is why you need critical care level trained paramedics and not ICU nurses in the aircraft - trust me I can't count the number of times I had full MD's defer to my judgment when the shit hit the fan in the back) This is why guard units have excelled - because you have guys with ten + years of real world experience bringing it to the table with a focus on doing the best job for the joe on the ground.
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-2 # RE: Excuse me while I step onto my soapboxDavid Prentice 2012-02-29 19:12
My understanding is that they still teach the same material and conduct the same training, but that they no longer do this with the goal of Paramedic certification for a variety of reasons.

Some that I suspect:
1. Civilian certification is only relevant to a civilian mission. A civilian mission is a secondary role for ANG PJ units, but may be a distraction for ADAF PJ units.
2. Civilian certification may be difficult, impossible, or simply a distraction for units which are deploying regularly to far off places where US civilian authorities don't exist and US civilian certified continuing education is impossible to obtain.
3. Graduating certified Paramedics is expensive. You need certified instructors and a civilian certified curriculum. You're requiring your war-tested instructors to maintain, or regain, a civilian certification which is meaningless in a warzone.
4. Operational Security. If you don't have a civilian certifying authority looking over your shoulder, you don't need to worry about the equipment you use or the techniques you teach being leaked out anywhere.
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+1 # Jealous Much?Heywood Jablomi 2012-02-29 19:55
Boy are you a moron.

PJ's far eclipse Army flight medics, and you know it. It is merely your own fragile ego that prevents you from accepting it.

As for no OJT? Bullshit. Both PJs and SOF medics do far more than any Army flight medic. Far more. It is intellectually dishonest of you to assert otherwise--unle ss you are just stupid or misinformed.

As for other skill sets, yes, both PJs and SOF medics do things other than just medicine. The real question is, why are Army flight medics so pathetically trained, when they do not do half of what AF special ops and Army special ops medics do?

Seriously. Army flight medics are not distracted by the need to train on methods of infiltration or warfighting skills. So why do you suck so much?

I will tell you why. Because that absurd building on Ft. Sam Houston has festered in its attitudes towards doing business the same way since I attended 91B AIT in 1980. By contrast, the SOF community has repeatedly revised its curriculum, and the current courses bear little resemblance to the old 300F1 course, OJT, and Med Lab.

If I am speaking Greek to you, maybe you should go sit in the corner and shut up and try to learn something.

Most of all, you should agitate within your own community for better training for flight medics. Most who simply rely on what they were taught are lame. They keep casualties company on the Blackhawk, and they look "real concerned" as they deliver the casualties to the CSH.

Yeah. Good work. Real elite. You jackass.
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+1 # NEW SOF 18DRom Rogers 2012-02-29 20:14
As a medic, you will be able to read and understand the nature of the training a SOF (it's now a joint program)18D goes through. I do know that it does not *sound* like you understand the their mission which drives the curriculum. The Army SF and Navy SEAL medic must be able to operate far away from and independent of any higher-level medical facility. Although they study subjects like pediatrics, they spend much more time on trauma and battle wounds than a civilian paramedic. Supposedly, a rotation through the Tucson ER and ambulance runs are sill part of the PJ curriculum. Who knows, the military is always changing things.

In recognition of your points about certification, USSOCOM has decided to bring all SOF medics up to the same standard and test them on it. a
After the initial exam, there will be continuing training and retesting every 2 years. Although current op tempo will keep 18Ds experienced, civilian paramedics are assured of experience every day.

Here is the best explanation from USSOCOM: http://tinyurl.com/7atg9p2

Here is an excerpt: In accordance with U.S. Code Title 10, Section 167, USSOCOM’s principle function is to prepare SOF for operations by organizing, training and equipping the force for its unique missions. Responsive medical education and training is fundamental to fulfilling this responsibility. When the medical needs of the modern day SOF were studied, it became clear that no existing certification program provided the advanced medical education, training and certification required. The need for the development of the ATP certification subsequently arose from the recognition that the current national civilian certification process, while working well for the civilian EMS sector, was not answering the requirements of SOF medics.

I think that you underestimate your skill in starting IVs and overestimate monkey skills.
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# soapbox 2ARNG Flight Medic 2012-02-29 18:19
I had PJ's tell me straight up that they would dump the medevac call they were on if a CSAR mission came available and that is unacceptable to me. We need a dedicated medevac that follows the civilian ambulance model with dedicated professionals in the back whose sole mission in life is to get joe back to his family alive. - I will step off my soapbox now!
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+2 # DrDavid Prentice 2012-02-29 19:04
As a former ARNG Flight Medic myself, I understand your frustration. However, I'm going to side with the PJ and say that they should drop the routine MEDEVAC in favor of a CSAR mission, even if the CSAR comes up while they're already enroute to pick up the MEDEVAC patient. I know it seems callous and cold, but I think that it is the harsh reality, and this is why:

The PJs are specialty trained and specialty equipped for a high intensity mission. Their training, capabilities, and equipment greatly exceeds what is required by the Army for a MEDEVAC mission. Furthermore, their mission cannot be delegated to a more generic asset, like an ordinary Dustoff bird. They cannot down-code their CSAR mission and hand it off to someone else.

You say you're an ARNG Flight Medic. So you understand Triage. You understand prioritization of resources. Simple Triage principles suggest that you match your problems with your available resources. The CSAR bird should take the CSAR mission and leave the MEDEVAC mission to a "lesser" asset to perform. You wouldn't expect a thoracic surgeon to do a job that could be done by a medical technician, when a thoracic surgery patient is waiting.

Sorry, I don't buy this bashing on the PJs business.

Is this about the PJ prioritizing the saving of one life over the saving of another? Thats a cold mechanical decision that falls under the heading of Triage. You learned this at Fort Sam. You had this reinforced at Fort Rucker. You know this.
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+2 # PrioritiesRom Rogers 2012-02-29 20:34
As David says, there are mission priorities and triage judgements. In the unlikely event that a pilot goes down, that is their mission priority and there are fixed wing and armed rotary wing assets searching for and protecting that pilot. So PEDRO has a date with that pilot and those other assets.

However, this is not the PJ's decision, it is his desire. The senior pilot in command of the two-ship PEDRO flight will decide what those 2 choppers will do.It depends upon the criticality of the wounded trooper and what the pilot is saying (if anything) on his emergency radio. The pilot in command will consult with both crews because another pilot or PJ might have more experience than he/she does. This is the military and the decisions are neither simple or easy. This is why the officers get the big bucks. {;*))

BTW, suppose the squawk comes in when they are RTB with a critical patient? That pilot in command will consult his PJs for their evaluation of their patient. When you set up a case study - don't make it easy.
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+1 # re: soapboxARNG Flight Medic 2012-02-29 21:56
I am sorry if my post came off as "hating" PJ's. They absolutely are trained way beyond the capabilities of the active duty army medic. Additionally you are correct that the CSAR mission is their mission and should be. My animosity stemmed from being overseas at a time when they were actively trying to take over the medevac mission, but not wanting to be dedicated to that mission.

I was not trying to disparage the capabilities or training of either PJ's or SOF medics -- but the missions are entirely different, and in the medevac bird you need medics whose sole purpose in life is medical care.

I have met good folks from all services, and if the airforce can do the job better than the army - then let them. but the bottom line is that the Joe on the ground deserves the best medical care he can get

as for "agitating" for change in my own community it was my company that pushed the data to the Institute for Surgical Research and forced the army's hand in challenging the status quo on flight medic training -- we pushed that line for a decade to anyone who would listen (mostly on deaf ears) until our data finally backed it up
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-1 # RE: re: soapboxHeywood Jablomi 2012-03-01 00:24
Quoting ARNG Flight Medic:
I am sorry if my post came off as "hating" PJ's. They absolutely are trained way beyond the capabilities of the active duty army medic.

I was not trying to disparage the capabilities or training of either PJ's or SOF medics -- but the missions are entirely different, and in the medevac bird you need medics whose sole purpose in life is medical care.

You still do not get it.

SOF medics, whether PJs or SOMED Ranger medics, SEAL or Navy Corpsmen or SF medics, are trained far in excess of any mere flight medic.

It is true that the respective missions of SOF medics and flight medics are different, but not in the way that you mean. The trauma management skills of SOF medics far eclipse yours. Further, they are trained in other specialties from obstetrics to veterinary skills. When I went through the SF Medic course in the early 1980's we did our own lab work using field kits by hand. It would be a huge waste of their expertise to stick them on helicopters to hold the hands of casualties, which is what you do, when you are not lounging around a ready room eating candy bars and playing X Box in your flight suit.

Ever been in a fire fight? I did not think so.

To state that Army flight medics are superior to special ops medics because "their sole purpose in life is medical care" merely underscores how misinformed and clueless that you are.

I would like to see a flight medic cope with the culminating trauma exercise at what used to be called Med Lab. You would choke. You would choke because you would have no frame of reference for handling trauma of that magnitude on a live subject.

Again, you need to go sit in the corner. Your words are a waste of air. You add nothing valuable to this conversation.

If you want to be relevant, man up and volunteer for service in special ops. Until that time, shut the f*** up.
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+2 # RE: Army Dustoff Medics UnpreparedJon1911 2012-04-17 03:53
Maybe we should ask the US Marine, who the British and USAF PJ's refused to evac, that is alive because Army DUSTOFF came and took him out, even though he had a RPG stuck in his leg, if he thinks they know what they're doing.
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+1 # Jon1911Michael Yon author 2012-04-17 04:01
Please substantiate your claim with names, place, date. This would be interesting to look into.

Thank you.
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+2 # DeconflictionBothSides 2012-04-19 08:02
OK.Its my turn for a soapbox. I have both sides of the fence on this issue. I worked for 4 years as a civilian EMT-P. I was a 68W after that, with a lower scope of practice, but a better paycheck. I am currently an Army Flight Medic, and I am typing this comment from Afghanistan, where I have been for the last 4 months running MEDEVAC missions. Nobody on this whole thread has gotten the story right yet. This includes the OP. Lets blow some of the smoke out of the room. The Army keeps statistics. I know this because its my buddy, a ground medic, who sits in the TOC watching mIRC windows waiting for 9 lines to drop and for the division assets to release the mission to us so he can give us the go ahead to launch. Every aspect of the mission is catalogued. Time from 9 line dropped to wheels up, time to MTF, everything. And every negative outcome is logged, questioned, interrogated, and then reported to division and higher. All Cat A pts are to make it to at least a Role II MTF within the Golden Hour. If not, we have to explain ourselves. Every Cat A mission MUST be wheels up within 15 minutes of the 9 line. If it is not, we have to explain ourselves. Every negative outcome (we picked him up alive, dropped him off dead) must be explained, in detail. All of these statistics are recorded, and reported. So, Idont know how accurate 92% is, but it is NOT fabricated due to lack of data. On to the second myth. Army flight medics hold a casualties hand till the MTF. This is bullshit. We may not have the EMT-P certificate to wave around like Pedro does, but that does not mean we do not train to the standard. ACLS, ITLS, PEPP, all this is standard Paramedic level fare, that the Army flight medic must remain current on. The only thing I was current on as a civilian Paramedic that Iam not current on as an Army flight medic is PALS. We are also OJT'd by our flight surgeon rigorously. Both our PA and MD spend hours drilling us in pathophys, pharm, trauma care, shock care, etc. I will say, that there I things I learned from these people that my EMT-P never gave me, and 90% of the flight medics I work with here are as good clinicians as any PA or doc you might come across. We do not always have time to fully incorporate our skills during a 15 minute flight from Pasab to KAF Role 3, but the skills are there. And they ARE practiced. And that idiot who said Ft Sam hasnt changed anything since the 80s is retarded and hasnt looked at Army medicine in a while. To Be Continued.
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# RE: DeconflictionRVN SF VET 2012-04-19 17:45
Thank you for taking the time to write from Afghanistan. I think that you are marrying 2 subjects that can be looked at separately. One is the medical qualifications and training of different types of health care professionals while the other is the MEDEVAC system.

The question of curriculum is addressed on the Fort Sam website. This Spring, they are finally changing the program of instruction after talking about it for 10 years - fact.

You are bringing your civilian experience to the fight and that same memo says that National Guard and Reserve medical evacuation units have better statistics than Active Army units - fact. My assumption is that these units bring superior training and civilian experience. A few of the flight medics have chimed in and spoken about the additional training that they got, at their expense, in civilian life. The Army only pays for the outside training of the 2 Reserve Component MAST units.

The critical data NOT collected are the outcomes. What happens hours and days are the casualty is delivered to the higher treating facility. BTW, as you know, the "Golden Hour" is not a magic solution. If a soldier is bleeding out and it can't be stopped, the Golden Hour turns into ASAP. 15 minutes can make the difference. What is truly confusing about this subject is who makes the MEDEVAC dispatch/approv al decisions. Part of the complaint has been the qualifications of the person manning the PEEC. Your description does not even mention a PEEC and your unit makes decisions at the appropriate level. Most of the gripes are about higher level decision making or not making. Some stories refer to waking generals up.

Lastly, there have been allegations by some, all the way up to the JCS, that 9 lines often exaggerate the severity of the casualty or the play down how hot the LZ is. If true, it is very sad, human, but sad as it affects other casualties' survival.
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+1 # Further DeconflictionBothSides 2012-04-19 08:28
Moving onward. I am not going to come down on PEDRO. Ive met the guys, and they are solid. They can go places with their HH-60s with the minigun that we cant get into without an AWT flying escort. They can carry blood products now, which is awesome. But then again, RC(S) command just signed off to start a program for Army DUSTOFF to begin getting blood products too. Both Army DUSTOFF AND PEDRO can perform advanced airway and resuscitation, AND take on ventilated pts. So, whatever that memo was, its out of date. The one thing that I will say about the PJs, is that the fact that their EMT-P and medical training CAN get buried under all of their other HALO, airborne, CSAR, dive training, etc. is true. They dont get to practice their clinical skills as much. That is NOT a mark against them, it is just the training constraints of someone with a broader mission scope than MEDEVAC. They still maintain a killer standard of care, and I would trust them with my life in a heartbeat. DUSTOFF medics, though, are not the light years behind that all of you seem to think they are. We maintain the standard. The only better care that you are getting out here aside from us or PEDRO is FEVER or the MERT, which both have physicians. Ones a C-130 and ones a CH-47, they dont have the flexibility that PEDRO and DUSTOFF have. We, as flight medics, might be Joes best hope. We know it, and we train for it. Dont imply otherwise.

Final 2 cents. I agree about the red cross, and the weapons, its only common [censored] sense. I also believe flight medics should get EMT-P as part of the standard, but only because it would help them after leaving the Army.

Also, the beurocracy doesnt hinder MEDEVAC launch the way some of you are implying. Our O-6 has NEVER been woken up to approve MEDEVAC. The launch decision lies with the BTL CPT. If the LZ is hot and we dont have an AWT that will make it there BEFORE we do, we will defer the mission to PEDRO. The ONLY time MEDEVAC is delayed waiting for escort is if its not up and PEDRO cannot take the mission. Even then, we find SOMETHING. We even had command allow us to count a B1B cruising over RC(S) as 'escort' so we could get Joe out in time. Before I get flamed for this, let me reiterate. I still think we should get weapons, any wait is too long a wait. Also, since many of you probably forgot int he course of my two-post diatribe. This is all coming from a 9 year EMT-P veteran. CURRENTLY working DUSTOFF in Afghanistan, as in I flew EARLIER TODAY. I have also talked to and had contact with the PEDRO guys. This information is up to date. Argue with me. Please.

Final side note: Coprsmen, really? I have no doubt any SEAL medic, 18D, W1 (SOCM) medic, etc. could run circles around me clinically and literally, but Corpsmen are not SOF. And as far as emergency medicine, in my experience, they are BARELY able to average up to todays 68W standard.
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-1 # RE: Further DeconflictionRVN SF VET 2012-04-19 17:58
Navy Corpsmen are in SOF as are PJs. Corpsmen are fighting SEALs. Often, on some ships, Corpsmen are the only medical person aboard. They have been trained to stitch and administer various drugs, intubate, and run IVs. SEAL Corpsmen get the additional medical training in the SOF medical course.

You have contributed greatly, but unless you check your facts first, don't critique other Service's medics. All the training these other Services require is available online. PJs for example do a tour in the ER at a Tucson hospital as part of their curriculum. Others on this forum have made similar mistakes when describing the training in other Services.
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+2 # RE: RE: Further DeconflictionBothSides 2012-04-20 05:06
I must respectfully disagree about the classification of Corpsmen as SOF. I have researched their training extensively. Their A school, plus FMF which is the special combat medicine sequence they go through if they are being assigned to marines, is the general equivalent of Army 68W AIT. They use EMT-B cirriculum and test questions as a standard just as the Army does. Corpsmen do get more extensive clinical or 'sick call type' medical training, including preventative medicine, treating infections and abcesses, removing toenails, and other such general upkeep medical care than your fresh out of AIT 68W does. But EVERY Army unit Ive had experiene with has their medics doing these exact procedures after minor training with the battalion PA. Corpsmen also have specialty schools they can go to for dental tech, respiratory therapy, etc. This is mirrored in scope of practice and training by the Armys other 68 CMF MOS's 68K,V,R, etc. I have worked with Corpsmen on multiple occasions during field problems, most notably while stationed on Hawaii. I participated in OEMS with them (live tissue lab) and in this realistic trauma environment the skillsets of the Corpsman and the 68W are almost exactly the same.

Corpsmen CAN get assigned to special units such as SEALS, etc., but they get more training for these assignments. Just as a 68W will go to SOCM school if assigned to the Rangers or the 160th, etc. These would be SOF Corpsmen, just as a 68WW1 (W1 being the SOCM ASI) is a SOF medic. The base job field of the Corpsman is NOT SOF. They do not at their base training level exceed standard Army 68Ws by any notable margin. They can both be assigned to an infantry unit, or a hospital. They may both be needed to provide primary care to the warrior for an extended time. Neither one of them are SOF.

Side note: secondary to this already similar standard of training, Corpsman school has recently been moved (or is shortly moving) to Ft Sam to be co-located with 68W school.
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# Both sidesMichael Yon author 2012-04-19 08:34
Thank you for the thoughtful replies. I need to read a few more times to soak in but have some deadlines to meet. Will get back, but you have brought up some important points. (I might not actually make another reply, but do want you to know these are important points and some of us will see that.)

Question on the side: have gotten various information about a Marine who recently died from electrocution. (I believe there actually were two separate electrocution cases: the case I am talking about was apparently on base involving a vehicle.) Dustoff side of the house mentioned there was a slow dispatch on that. Got any info?

Thank you again...importa nt feedback. (pls ditch the curses...kids come here.)
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# apples/orangesLonestar doc 2014-08-18 16:15
When did all this become a measuring contest? It is a fact that most missions I went to, the patients were already "packaged" for transport and the only treatment rendered was CPR or monitoring vitals, but I have been on mast when a MD came along and he couldn't start an iv or intubate when faced with on-site conditions. I have respect for all who are doing aeromedical tasks whether 18D/PJ/68W/Pilo ts/Crewchief/gr unts/squids or the guy who picked up FOD on the lz. The mission is a team effort and ego should be left on the ground. Pride is only as good as the man talking, but its a different kind of military now. I miss the days when men of honor ran into battle and didn't have to be given praise for doing his job, respect is earned but bashing is beneath the standards of all who accept the call.
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# MrDJ 2015-09-24 01:40
Wait, i get it. You're trying to sell books.
Ok then. Too bad that your sales will come from bashing Army FM's and DUSTOFF. You're word is shit.
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