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MEDEVAC Issues

20 August 2012

This is a bit technical, but of interest to the MEDEVAC community:

J Trauma Acute Care Surg. 2012 Aug;73(2 Suppl 1):S32-7.

Impact of critical care-trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan.
Mabry RL
Apodaca APenrod JOrman JAGerhardt RTDorlac WC.

Source
From the US Army Institute of Surgical Research (R.L.M., A.A., J.P., J.A.O., R.T.G., W.C.D.), Fort Sam Houston, San Antonio, Texas.

Abstract
BACKGROUND:
The US Army pioneered medical evacuation (MEDEVAC) by helicopter, yet its system remains essentially unchanged since the Vietnam era. Care is provided by a single combat medic credentialed at the Emergency Medical Technician - Basic level. Treatment protocols, documentation, medical direction, and quality improvement processes are not standardized and vary significantly across US Army helicopter evacuation units. This is in contrast to helicopter emergency medical services that operate within the United States. Current civilian helicopter evacuation platforms are routinely staffed by critical care-trained flight paramedics (CCFP) or comparably trained flight nurses who operate under trained EMS physician medical direction using formalized protocols, standardized patient care documentation, and rigorous quality improvement processes. This study compares mortality of patients with injury from trauma between the US Army's standard helicopter evacuation system staffed with medics at the Emergency Medical Technician - Basic level (standard MEDEVAC) and one staffed with experienced CCFP using adopted civilian helicopter emergency medical services practices.

METHODS:
This is a retrospective study of a natural experiment. Using data from the Joint Theater Trauma Registry, 48-hour mortality for severely injured patients (injury severity score ≥ 16) was compared between patients transported by standard MEDEVAC units and CCFP air ambulance units.

RESULTS:
The 48-hour mortality for the CCFP-treated patients was 8% compared to 15% for the standard MEDEVAC patients. After adjustment for covariates, the CCFP system was associated with a 66% lower estimated risk of 48-hour mortality compared to the standard MEDEVAC system.

CONCLUSIONS:
These findings demonstrate that using an air ambulance system based on modern civilian helicopter EMS practice was associated with a lower estimated risk of 48-hour mortality among severely injured patients in a combat setting.

LEVEL OF EVIDENCE:
Therapeutic study, level II.

Comments   

 
+4 # Mr.Tim 2012-08-20 17:25
Great post Michael, the technical points are that the U.S.A. Institute of Surgical Research says that an advanced level of care provider similar to what is today provided in most U.S. civilian air medicine can drastically decrease mortality - BUT ONLY IF THEY CAN GET TO THE CASUALTY IN TIME (commenters comment and emphasis, not in the study). Overall we can continue to reduce morbidity and mortality IF we can get to the patient - and silly 9 line messages and turf wars over who can or cant go because of what is painted on the aircraft shouldnt matter! Continue the good fight, there are lots of quiet warriors taking the line with you Michael!
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+1 # RE: MEDEVAC IssuesHeath 2012-08-20 17:59
Hopefully more good & positive changes to this issue will happen. Keep up the good work and contact your congressmen & senators on this issue. That could be your son or daughter or grandson or granddaughter someday if they decide to volunteer for U.S. Military duty or are issued their military draft cards. Keep the U.S. Military in your prayers. Hopefully the next U.S. President will take notice of this issue and something good will come out of this.
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+5 # RE: MEDEVAC IssuesDang 2012-08-20 18:05
Wonder how the study accounts for the conditions under which the missions are flown. Few to none of the CCFP-based data points come from tactical conditions, hostile fire incidents, etc. Delays in launch time will no doubt continue to be the "long pole in the tent."
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+4 # retired PJRAW 2012-08-20 18:10
The military could have done an apples to apples comparison without having to extrapolate data comparing civilian paramedics and MEDEVAC EMT. Look at survival rate of casualties picked up by Pedro (PJs--best trained combat medics on Earth) and compare that to DUSTOFFS.
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+2 # RE: retired PJrcrogers6 2012-08-20 19:38
Excellent points Pedro would have been a much better comparison. Also, remember the National Guard unit whose personnel have civilian jobs with advanced life support training - some at their own expense and some at government expense because the Guard unit was a MAST unit flying civilian missions in their state. Michael posted a letter study from a colonel who visited Afghanistan and noted that the Guard unit had better outcomes than Active Army units.

Another problem with the study is that how can you compare some of the combat trauma with traffic accident trauma? Still, the study's conclusion is correct, but it would be more dramatic if if were apples to apples.
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+1 # platoon FMF corpsman, VietnamKent Hill 2012-08-21 02:19
The U.S. Army continues to skirt the real issues when are Medevacs versus Dustoffs, used in combat situation and who makes that determination.
When I called for a medevac in Vietnam, I specified whether I needed medical personnel with either a physician, a Marine corpsman or an Army medic.
I would always radio for the Marine medevacs first, as the Marines would fly anywhere, anytime and get to our LZ faster, whereas the Army medevacs would generally only fly into a secured LZs and take 30-45 minutes longer than their Marine counterparts.
It sounds like nothing has changed in 43 years since 1969 when I was in the Republic of South Vietnam and Laos and today in Iraq and Afghanistan/Pakistan.
The generals and the U.S. nilitary chain-of-comman d along with the military-indust rial complex seem to be the only entities that are getting rewarded for doing a less that outstanding job for those willing to give their lives Our country.
Semper Fi U.S. Marines and FMF Corpsmen!
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+1 # ms.karen 2012-08-21 16:18
well done... GOD bless you
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+1 # RE: MEDEVAC IssuesHeath 2012-08-21 18:17
Our servicemen ( our sons & grandsons nephews cousins. ) are dying on our helicopters and the serviceladies ( our daughters & granddaughters nieces female cousins )on the helicopters have no armed protection from gunfire coming from both ground and air and not only that tbe medic bases probably for all we know comes under frequent mortar attack etc. We need to have armed UAV's monitoring the mountainside on better visual technology for FLIR cameras to shoot down any terrorists attempting to set up a mortar crew against our medic bases etc. Same with covering the roads with armed UAV's so that nobody plants IED's and immediately be shot if there is even an attempt to plant IEDs in the roads to the medic bases. We need a better plan when it comes to the issue of medic helicopters being heavily armed to the teeth. Michael Yon, I have often thought the Cobra helicopter could have expanded doors and medic personnel on there. The Cobras are armed to the teeth. Make a medic version of the Cobra helicopters. I wonder why nobody has thought of that, In the meantime we need to do what we can to arm our medic helicopters with everything in the U.S. Military arsenal. Mike Yon, I hope you are called back to active duty to help with formulating the new helicopter plan for the medic personnel. If the U.S. Army brass is smart enough, they will re-hire you back into uniform and tell you whatever it takes, you got it and it actually gets done with un-fettered access. THE FASTEST WAY TO STOP ANY FURTHER EMBARRASSMENT FOR CONGRESS AND SENATE AS WELL THE U.S. ARMY BRASS IS TO HAVE SOMEONE WHO IS SERIOUSLY CONCERNED ABOUT THIS BE THE POINT MAN AND I THINK YOU ARE THAT POINT MAN. I hope the U.S. Army brass listens to my suggestion to have you be in charge of the helicopter program and you can work with your Army buddies to get things done for real. Re-vamp our helicopter plans. My prayers go with you and God Bless you Michael Yon & God Bless America.
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+1 # RE: MEDEVAC IssuesHeath 2012-08-22 18:44
Michael Yon, do you remember the tv show " Air Wolf " from the 1980's ? Combine that with the Cobra's flying ambulance armed to the teeth in the mountains of Afghanistan or anywhere in the world. As I understand it " Air Wolf " was only a concept in the 1980's but now today's technology & stronger materials needed for a military flying ambulance can be a reality today on the modern battlefield. 8)
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+1 # RE: MEDEVAC IssuesRVN SF VET 2012-08-22 18:50
This problem is first and foremost a policy and procedures problem and not a hardware problem. Hardware improvements take time, but the ideal air ambulance is a worthwhile development project with both military and civilian vale.

But, by a signature on a piece of paper, the Army MEDEVAC problem could be solved instantly and then improved over time to raise the statistics on 48 hour outcomes.
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+1 # ABAB 2012-08-23 16:29
I have to wonder if speed in evacuation can also sway the numbers. I am not referring to the typical way of thinking in that a quicker evacuation will have a better outcome, but rather the thought that a platform that consistently arrives at the point of injury earlier than other platforms, and deliver the most severely wounded patients to a medical treatment facility before they die in the field. Such could easily be the case with Dustoff aircraft given their greater numbers in theater (there are five Dustoff aircraft in Afghanistan for every one Pedro aircraft) and their overall consistently faster evacuation times. In a one year period as a Dustoff Ops guy, the statistics that we maintained showed that our actual mission time from TIME OF INJURY (a more critical factor vs. time of launch) and time of delivery to a surgical capability was much faster than all other platforms to include Pedro and Tricky. Given the larger fleet performing MEDEAC throughout the theater, the statistic alone would be skewed. But when we could deliver many patients who would have typically died before pick-up by other platforms because they were slower in response, and they die despite the best efforts of the medical personnel to whom we delivered them to, would that not also skew the numbers further? Was there a thought by those who performed this study to determine what patients would die no matter what interventions were given and remove those numbers in the statistics? I’ll bet money that they didn’t account for that factor.
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