Imagine you’re part of a patrol heading out from the forward operating base in southeastern Afghanistan near the Pakistan border where you’ve been living for the past three months.
You have a few months remaining before you head home to the family and the loved ones you’re missing. They’re missing you, too, and praying for your safe return.
A couple of hours into the patrol the world goes silent, but you won’t realize that for hours, perhaps days. Your Humvee has hit an IED.
When you do wake up, you’re far from the sand and heat you last remember. A friendly face explains where you are and what has happened since your last memory—the explosion that landed you here.
You’ve been expertly treated and are now in the capable hands of the medical team at Landstuhl Regional Medical Center in Germany.
For many troops, the beginning and end of this story is too familiar. The middle sections, however, may be a bit unclear. What happens between a troop getting injured on the battlefield and waking up at Landstuhl—ideally stable and possibly awaiting the trip home—may not be common knowledge to those at home, either.
But the process represents incredible teamwork by dedicated individuals in our military.
The Golden Hour
When injuries are sustained on the battlefield, far from Level 3 or even Level 1 trauma facilities, the care received in the next 60 minutes—the Golden Hour—is critical.
“Most providers say that if you get the best care to that patient within that frame of time they have the greatest chance of making it to the next site ... to get continued care,” said Army Lieutenant Colonel Mark Crago, M.D., 82nd Combat Aviation Brigade Surgeon deployed to Bagram Air Base. “It’s a time frame that we try to meet—getting from here to the site and back [with] the patient. Again, it’s just a system. It’s a line in the sand, so to speak.”
While the post-injury hour is critical to increasing the chance of survival, it’s really the actions of those who attend to the individual that make the most difference—whether it’s a troop applying his own tourniquet or his battle buddy who renders aid.
“The people who have the most important role are the
people who have that patient at the time. Either providers at the
lowest-level facility, the combat lifesavers and just Joe, who
knows what he’s doing and … was trained to use this stuff at Basic
[Training],” he said. “So then, all of a sudden it becomes us who
[have] the most important job, because we’ve got to then take that
patient from the point of injury or the hospital to the next level
Crago and his crew can be called for a point of injury medevac mission or a transfer from another facility where a forward surgical team (FST) has stabilized a patient—stopping bleeding and working to save limbs. As a result of these lifesaving measures, patients may have apparatus that can make their transport tricky. So, the last step before handing a patient off to Crago and his team is to “package” the individual.
“Taking patients from that nice, warm surgical room and putting them into an aircraft that’s freezing cold—and there’s a lot of tubes, wires, drains, things like that—you don’t want those flapping in the breeze,” he said. “So we say they package them up. They put them in warmers … get all those extraneous wires and tubes [secured].”
Crago emphasized that capitalizing on the Golden Hour is a team effort. Those efforts, combined with training, advances in medicine and protective gear are saving lives. But, as are most things military, these measures are not for the glory of those working to save lives. They are for the glory of life itself, whether that life is an American troop—human or military working dog—Afghan local or insurgent.
The latter had been the doctor’s last patient.
“That’s one thing that’s wonderful about America. We value life and value keeping people alive,” he said. “Life is important. We try to give everybody the same level of care.”
Sometimes that care isn’t as routine as the usual, though critical, cases.
Flight medic Army Sergeant Joshua Lee Munn said his first night as part of a medevac crew fell into the unusual and unnerving category.
“We [got] a call for an RPG wound to the shoulder. We get there and there’s a lodged RPG in his shoulder. Not detonated. Warhead intact,” he said with the amusement that only surfaces when you’ve dodged a figurative bullet … or a real RPG. “We had EOD [explosives ordinance disposal] waiting for us, but he was already in [the helicopter] by the time we figured it out.”
The crew rushed the patient to Bagram without further incident before they handed him off to the emergency medicine team.
Even after what could have been a very hairy situation, Munn enjoys what he does calling it the “most rewarding job.”
“It’s the most amazing thing I think anybody can ever do—to bring somebody’s son, father, daughter, mother back to their family,” he said.
Also amazing is that nobody has ever died on their medevac flights, Munn said, offering a simple explanation.
“We will either be breathing for them or pumping their heart for them,” he said. “So we will be doing CPR—whatever we can to keep them alive. That’s what we go for.”
Level 3 Trauma Care
Once the medevac Black Hawk helicopter has touched down at Bagram Airfield, the distance to the emergency room at The Craig Joint Theater Hospital is short. The emergency department team is awaiting the patient’s arrival and ready to continue treatment in an emergency room heated, not for the patient’s comfort, but for their safety. Cold blood doesn’t clot as well as warm blood.
This is just one concern for Air Force Major Roy Johnson, the hospital’s emergency medicine flight commander. His team is ready and waiting for the handoff. Instantly, they’re working to stabilize the patient if needed—each team member working their piece of the game plan, ensuring the patient has the best possible chance for survival.
Johnson compares the process in his emergency department to the way an ER in the States would handle a similar situation. In fact, Johnson’s ER can provide trauma care equivalent to any large, major trauma unit in the States, he said, adding that his team is probably better at treating blast wounds and amputations because they’ve seen so many more of those types of injuries than the doctors at home.
Actually, the most prevalent injuries seen in the Bagram ER include those from mounted and dismounted—in vehicle and outside of vehicle, respectively—IED explosions and gunshot wounds.
The most traumatic injuries, as one might imagine, are the dismounted IED blasts.
“The body armor’s done an excellent job of protecting your thorax, but your extremities are still vulnerable,” Johnson said. “So we see a lot of amputation, and then, when the debris [flies], you’ll see a lot of penetrating injuries from the debris.”
But Johnson and his medical staff are well-trained and prepared for their roles in treating these types of traumas. The team includes four physicians, one physician’s assistant, six nurses and 13 ER technicians.
These individuals come from all over the Air Force.
Johnson was serving as an Air Force security officer when Oklahoma City’s Alfred P. Murrah Federal
Building was bombed. After watching a doctor treat people in the aftermath, he decided to change his career path so he, too, could help people in a more meaningful manner.
Some of the team members honed their emergency trauma care skills in some of the toughest ERs in the county, including Baltimore Shock Trauma, St. Louis University and a program in Cincinnati.
“They come here, some of them may not be quite up to speed on the level of trauma that we see, but they’re all motivated,” Johnson said. “We have the best job in the Air Force. We get to provide care to guys that have gone out and volunteered for their country and gotten really hurt, and we give them the best chance for survival and function that we can.”
When Johnson and his team are finished the focus turns to getting the patient to Landstuhl Regional Medical Center. It’s the Contingency Aeromedical Staging Facility, or the CASF, in local parlance, that does the heavy lifting to make that happen for the patients that doctors deem stable enough to make the nearly eight-hour flight. Those who are stable often stay in the CASF’s temporary, 21-bed housing facility, thus freeing up hospital beds for those who will come behind them.
They don’t stay long, though.
Air Force Lieutenant Colonel Carolyn Pignataro sees to that. She’s the CASF’s flight commander and is in charge of movement through the CASF, which is a comfortable, but austere facility near the hospital.
“We provide the manpower and communication and coordination of aeromedical evacuation (AE) at Bagram Airfield,” she said. “We also house stable patients for aeromedical evacuation.
“Usually once or twice a day we’ll get one or two or three patients from the ward transferred to us,” she added.
While the patients at the CASF wait for one of the several scheduled aeromedical evacuation flights each week, they can relax and read, watch a movie or play games. Resting up is encouraged, Pignataro said.
The number of patients aboard each flight can vary as wildly as the needs of the patients. The condition of those aboard can range from being mobile and requiring minimal care to CCAT, or Critical Care Air Transport Team—patients who basically need an ICU team to travel with them and ensure their stability during the flight. The medical and CASF staffs aren’t the only ones keeping an eye on patient numbers at Bagram. The Joint Patient Movement Requirement Center in Qatar also monitors the situation, and if beds become an issue in the hospital and the CASF, they work with Bagram to schedule additional AE flights.
Regardless of how many flights leave Bagram each week, the CASF and hospital staffs, and the volunteers who load patients onto an ambulance bus, or AmBus, and then onto the plane, are there to see the patients safely on their way to their next stop on their road to recovery.
The continuum of care
When the aeromedical evacuation flight lands eight hours later at Germany’s Ramstein Air Base, the patients still have a short bus ride to Landstuhl Regional Medical Center—a Level 4 trauma facility.
Here patients receive additional care—minor or major—before becoming a recovering outpatient or preparing for one more AE flight home to a major military medical facility in the States.
South Carolina Army National Guard Specialist Travis P. Taylor fell into the latter category. He was the victim of a vehicle assault during a routine mission.
Stationed at FOB Geronimo, nearest Camp Leatherneck, Taylor and his unit—an agricultural development team—headed for Marjah, an agricultural district in Afghanistan’s Helmand province. They reached FOB Marjah—run by the Marines—that evening.
“The next morning we went out because we were going to go through the bazaar, which is only a couple hundred meters away from the FOB,” Taylor said of the market, which he estimated to be a mile long.
“It’s a pretty decent little place.”
As his team inspected the produce at each stand, Taylor provided security. The inspection was uneventful. As they were heading back to the FOB, however, the dust started churning as a vehicle engine roared.
“Normally, through that area, the [Afghan National Army] and [Afghan National Police] have their vehicles and they drive around like crazy people. Just hauling butt,” he explained. “We wave to them and tell them, ‘Hey, can you please slow down?’
They don’t usually take that very well … so it’s not an uncommon occurrence to hear an engine roaring and flying by.
“You don’t really think anything of it,” he said. Until, of course, that roaring engine doesn’t sound right.
“Just as I turned around, I saw a … white Toyota Corolla fly up and hit one of my buddies in the arm,”
Taylor, who froze momentarily, said. “I kind of felt like it was an accident until I saw the vehicle turn … and fly at me. At that point, I was just kind of awestruck.”By the time he snapped out of it, the car was a foot in front of him.
“All I could do was just close my eyes,” he said. “It hit me and I rolled up and over the vehicle. I remember opening my eyes and just staring at the sky—seeing a couple of clouds go by.”
Seconds later, he was on the ground, hearing people yelling. Deciding that playing dead was the right approach, he lay where he fell—having already tried to stand and realizing he was incapable. His team dragged him in to a wadi, or a ditch, and the medic assured him he was going to be OK. Then there was gunfire.
“My squad leader came over and said that they had got the guy who did this to us,” Taylor said, adding that their local interpreter had been killed. “At that point the Marines pulled up with their vehicle.
“I tell you what, those guys were Johnny-on-the-spot. They jumped out, put me on a stretcher, lifted me up, put me on the back of their vehicle,” he said.
“It was well-rehearsed. They had the bird [helicopter] come down and while I was waiting … they gave me this little lollipop thing. It knocked me out.”
His memory of the events after being loaded onto the helicopter are fuzzy—he thinks he went to Kandahar before routing through Bagram. Regardless, he was treated and put on an AE flight to Landstuhl sporting a plaster cast on his arm. Despite the events that landed him in the ward awaiting the trip home, Taylor maintained his sense of humor.
“It was an experience,” he laughed.
A good one, though.
“Very, very, very reliable,” he said. “You even raise your arm like you’re trying to get somebody’s attention on accident and there’s like four of them just, bam, right on you.”
Upon arrival at Landstuhl, Taylor learned a fixator had been screwed into the bones of his broken leg to keep it perfectly straight as it healed. As it turned out, he had a fracture under his kneecap and a broken ankle.
“My thumb is broken … I don’t know if you can see, but I’ve got black and blues all … over the place,” he said. “I’ll tell you what, though, that car thought it was going to win. The driver, I guess, thought he was going to hit me from behind.
“I’m six-foot seven, so I think that’s probably what saved me.”
Injured on a Monday, Taylor arrived in Landstuhl the following Wednesday. He hadn’t had any surgeries other than to install the “erector set,” as he called it, and his treatment was still up in the air, but he knew he was looking at a trip home to recuperate.
And, as in Bagram, Taylor may have stayed in the CASF at Ramstein Air Base where AE flights pass through, delivering patients from theater and picking up those headed for home.
Also like the CASF in Bagram, the number and condition of patients can vary widely.
Air Force Major Maria Coppola, 86th Aerospace Medicine Squadron flight commander in charge of the CASF, said the number of patients ready for transport was more in line with numbers three years prior.
“People think because we’re out of Iraq that the numbers have decreased, and I guess in the big scheme of things, if you look at the historical data since 2001, yeah, our numbers have decreased,” Coppola said. “We do see an increase in injuries during the summer months.”
Because the CASF at Ramstein is so far from the hospital at Landstuhl—unlike Bagram—the job of checking on patients still on the ward and those at the CASF becomes a two-part mission. Theater Patient Movement Requirement Europe personnel check on patients still at the hospital, while the flight surgeon at the CASF checks those patients.
“Most of the questions taken care of in the morning [just before the flight] have to do with where their final destination is, do they have enough medications—things that may have gotten missed the night before—or if there has been any change through the evening,” she said of the pre-flight procedure.
Ultimately, the flight surgeon has the final say over whether a patient gets on the flight, but the patients that make the trip are still in the best of hands even miles above earth, whether they’re critical or not. The CCAT doctors, flight nurses and technicians see to that.
While each patient continues to receive the same high level of care they’ve received beginning at the point of injury, the critical care patient become a major focus.
“The idea behind AE, and even CCAT, is that it’s a continuum of care,” said Air Force Major Jeffrey
Simmons, the CCAT doctor with the 86th Aeromedical Evacuation Squadron at Ramstein Air Base,
Germany. “The idea is that you would not transport them if during that transport they can’t get … the care [they need]. “
In other words, if a CCAT patient needs something that he or she could normally receive in a land-based ICU setting, it will be available to them in flight, he said.
To make sure its patients’ conditions don’t deteriorate during the flight, the crew flies with some specialty equipment, including portable therapeutic liquid oxygen, an Advanced Cardiovascular Life Support drug kit and everything from Tylenol to atropine, said Air Force Sergeant Julie DePriest, the crew’s technician.
Some of their equipment requires power, which may be plentiful in a hospital ICU, but not in an airplane.
“A lot of our equipment can’t plug directly into [the aircraft power source]. So we take that black box,” she said, pointing at a Unitron frequency converter. “We can actually plug that into the aircraft and it converts it into hospital-grade power that we can plug our equipment into.”
To have this capability available is critical, especially during fighting season—spring and summer.
“There are some sports injuries and there are some medical illnesses that you would expect, but I have seen a lot more battle injuries pick up in the [summer months],” Air Force Major Brenda Hackenberg said.
Regardless of the injury, the patients are just ready to get on with their recoveries, said Air Force Captain Carly Edwards. She and Hackenberg are both flight nurses with the 86th Aeromedical Evacuation Squadron.
“Most of them are ready for their definitive care,” she said. “The recovery process in general is somewhat traumatic, depending on what’s going on with them.
“So they’re kind of ready to get to the final point and just get it done,” she said. “A lot of these patients are going to take several weeks to recover from whatever happened to them, but most of them are very grateful for us caring for them and they are excited to get back to the States.”
The gratitude is mutual. The Army medevac helicopter crews are often referred to as Dustoff crews. Dustoff is a nickname for their motto, “Distinguished, Unhesitating Service to Our Fighting Forces.” That nickname should be used for each and every caregiver along the way—from the first person to render aid on the battlefield to the last one that hands that patient off to their definitive care team.
Samantha L. Quigley is the editor in chief of ON★PATROL.