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«FINAL REPORT 30 January 2013 U.S. Central Command Pre-Hospital Trauma Care Assessment Team Russ S. Kotwal, MD MPH COL, MC, USA Director of Trauma ...»

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77. The current US 60-minute evacuation time requirement refers to the mission time after the 9-line evacuation request is approved. There can be delays before the 9-line is sent and occasionally in the approval process as well. (BAF Role I – USAF Pararescue)

78. Consider combining and requiring a “MIST” Report for 9-line MEDEVAC requests. (MIST = Mechanism of Injury, Injuries, Signs/Symptoms, Treatments).

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outcomes. The UK MERT CASEVAC has been giving blood products during TACEVAC for several years, and USAF Pararescue CASEVAC and USA DUSTOFF MEDEVAC are now doing it as well. EMT-B medics can be trained to provide blood component therapy.

Preparations for transfusion should be accomplished prior to arrival at the point of injury as dictated by the 9-line evacuation request and the MIST reports. It is desirable to have at least two medics on the evacuation platform when blood is being given. (Theater Trauma Conference – RC-S and SW MEDEVAC Medical Director and EM Physician)

80. USAF Pararescue personnel conducting CASEVAC noted that they do not give plasma because it takes too long to resupply. (Bastion Role 1 – USAF Pararescue, BAF Role 1 – USAF Pararescue) As a follow-up, this issue was discussed with COL (Ret) John Holcomb, now the Chief of Trauma at Memorial Hermann Hospital in Texas. Memorial Hermann gives both blood and plasma pre-hospital when indicated on their helicopter ambulance service. Dr. Holcomb’s input: Thawing the plasma is a real time sink. We have now had thawed plasma on 4 helicopters for 14 months, but switched to liquid plasma last month. Thawed plasma is good for 5 days. Liquid plasma (never frozen) is good for 26 days. Our service decided not to use the Golden Hour Box, but they use something similar. If plasma is not used, and the storage temperature is controlled, we put the plasma back into the hospital stock at day 3 for thawed or day 15 for liquid so we can avoid wasting the product.

81. Given current short transport times, few casualties on U.S. evacuation platforms receive more than one unit of blood product during TACEVAC flights, although the UK MERT platform often transfuses larger volumes of pre-hospital blood and plasma. If transport times increase, or larger platforms allow more medical personnel, it may become possible to transfuse more units of blood products and then plasma may become more important. There are additional issues associated with getting liquid plasma to the combat zone. Would you get it from the U.S.?

(average age for PRBC transfused in mass transfusion is 23 days) Would you pherese it in theater? (JTTS Deployed Director)

82. Salerno FOB National Guard DUSTOFF unit has trained paramedics who are also critical care flight paramedics in the civilian sector. Bagram Airfield Active Duty DUSTOFF unit (Shadow DUSTOFF) is promoting paramedic certification as an internal unit initiative.

83. The USAR 11th Aviation Regiment is developing a partnership with Memorial Hermann Hospital and “Life Flight” for trauma center rotations to support the pre-deployment and sustainment training of their medical personnel. This effort should be supported, expanded, and used as a model of excellence. (JTS Trauma Care Delivery Director)

84. There are two crewmembers in the back of the aircraft on Shadow DUSTOFF missions – the flight medic and the crew chief. The crew chief routinely assists in casualty care and should be trained at least to the EMT-B level. Currently, an Emergency Critical Care Nurse (ECCN) will frequently augment flights. (JTTS Deployed Director) Both should be trained in TCCC as well.

(CoTCCC Chairman)

85. ECCNs bring a higher level of medical capability (advanced airway management, mechanical ventilation, hemodynamic and vasoactive medication management, advanced assessment skills) as they augment flights with medics during POI missions, in addition to transfers of critically ill and injured between MTFs. (JTS Enroute Critical Care Director)

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theater. They are not authorized flight pay or flight wings. Some units do not allow ECCNs to officially track flight hours or complete readiness level progression because they are not official crewmembers. (JTS Enroute Critical Care Director)

87. ECCNs are currently Medical Brigade assets. However, they do not deploy at the same time as the medical brigade or MEDEVAC units. This causes issues and variability with training, awards, team-building, trust, and consistency in mission. (JTS Enroute Critical Care Director)

88. There are meetings with USA MEDEVAC personnel and USAF CASEVAC personnel every other Friday. Both evacuation systems are capable of giving blood enroute, but neither is doing so currently in the KAF system due to administrative issues. Both systems are using and like ketamine. There have been no known adverse effects from pre-hospital ketamine in the KAF AO. (KAF Role III – Intensivist)

89. USFOR-A is currently acting to develop and refine an advanced medical evacuation capability for US forces. (USFOR-A SG) Two pending papers will show that this advanced evacuation capability reduces mortality in severely injured combat casualties. (CoTCCC Chairman)

90. MEDEVAC unit personnel recommend that designated MEDEVAC (DUSTOFF) aircraft with red crosses be sustained in order to preserve a dedicated platform for this mission. (Shadow DUSTOFF) However, CASEVAC unit personnel note limitations of MEDEVAC aircraft (red crosses, lack of weapons) as well as limitations in MEDEVAC crew training (tactics and weapons training). (UK MERT CASEVAC, USAF CASEVAC) A dedicated platform capability should not solely dictate the mission requirement; the mission requirement should dictate both a dedicated platform and a dedicated medical capability. The goal is to decrease time to damage control resuscitation and damage control surgery. (JTS Trauma Care Delivery Director)

91. Patient Evacuation Control Cell (PECC) intelligent tasking is occurring in the Afghanistan Southwest Regional Command. Experienced emergency medicine and intensive care unit nurses are being assigned and utilized at the PECC. Clinical and tactical concerns are considered during tasking, and the most appropriate tactical evacuation asset is employed.

Although strong clinical experience is vital, intelligent tasking algorithms and a matrix should be developed and refined.

92. A better defined list of injury severity and recommended evacuation categories would be very useful. Tactical factors should be considered in the evacuation process, such as a Soldier who is part of a foot patrol who suffers a badly sprained ankle. (KAF Role III – PECC Nurse)

93. The PECC may upgrade an evacuation if needed, but they do not downgrade the evacuation categories submitted. (KAF Role III – PECC Nurse)

94. With the drawdown of forces, it may prove difficult to maintain current evacuation times.

Additionally, it may prove challenging for Afghan forces to provide organic evacuation. The challenge may be to keep the percentage of preventable deaths at current levels.

95. For the USAF Pedro & Guardian Angel Team, casualty evacuation is normally a third priority behind CSAR for US forces and CSAR for Coalition forces. Pedro has increased tactical capability secondary to Forward-Looking Infrared (FLIR) imaging system and weapon systems.

MEDEVAC platforms with Red Crosses versus training with weapons? Red Crosses may serve to dedicate a platform for evacuation; however, do modern mission requirements dictate Unclassified Unclassified armament? A “paradigm shift” is needed for Army tactical evacuation. (Bastion Role I – USAF Wing Commander)

96. For USAF units conducting CASEVAC, Category A and B missions are never refused.

(Bastion Role I – USAF Wing Commander)

97. UK MERT CASEVAC is often used for CAT A or multiple casualties; the MIST report is often unclear about the need for blood; MERT flies with 4 units of thawed plasma and 4 units of PRBCs and turns units back to blood bank if not used; the platform carries D oxygen cylinders and has a maximum capacity of 8 stretcher casualties. (Bastion Role I – UK MERT)

98. The UK MERT CASEVAC takes the Emergency Department to the Point of Injury. There is a publication pending in Annals of Surgery that studies the effect of the MERT on casualty survival; for casualties with an Injury Severity Score (ISS) of 15-50, mortality in casualties evacuated by the MERT was 12.2% as compared to 18.2% on the non-MERT platform. It is unclear at present which aspect of the advanced capabilities of the MERT is most important.

(Theater Trauma Conference – Bastion Role III US Anesthesiologist speaking on behalf of UK Col Rob Russell)

99. The US is currently developing an advanced evacuation capability platform that will incorporate many features of the MERT model. The capability is expected to be operating soon.

(Theater Trauma Conference – BG Van Coots, USFOR-A Surgeon)

100. The USAF Pedro & Guardian Angel Team is the casualty evacuation method of choice when: High threat levels are present; the landing zone is small; or a hoist is needed for evacuations from mountain settings (Bastion Role I – UK MERT)

101. The USAF Pedro and Guardian Angel Team’s primary mission is CSAR which is an offensive mission, and the secondary mission is CASEVAC which is a defensive mission.

Overall capability can be reduced to three capabilities working in harmony: 1) medic and medical capability, 2) aircraft platform capability, 3) pilot and crew capability. Tactics and weapons training is essential for Role I personnel. (BAF Role I – USAF Pedro Pilots)

102. Casualty Evacuation is not the primary USAF Pedro and Guardian Angel Team’s mission.

This mission was assigned to USAF rescue units to help achieve compliance with the Secretary of Defense’s mandated 60 min evacuation time limit. Coverage is not complete in Afghanistan even with USAF support. Operations in areas not covered by the 60-minute evacuation time rings require 4-star approval. (BAF Role I – USAF Pedro Pilots)

103. Reported evacuation times are from the time that the approved 9-line evacuation request is received by the evacuation unit until the aircraft arrives at the medical treatment facility. The average time to launch after the 9-line is received is presently 8-15 minutes. (BAF Role I – 1st Infantry Division) The time intervals from wounding until the 9-line is sent and the time required to approve the evacuation mission are not tracked. (BAF Role I – Shadow DUSTOFF) The time interval from wounding until arrival at the medical treatment facility may therefore be somewhat longer than reported evacuation times. Launch preparations routinely begin before the mission is approved.

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for evacuation platforms and contingency planning for non-permissive environments is critical.

Delays of hours to days in evacuation were seen in Afghanistan and Iraq early in these wars and contingency evacuation plans included donkeys and other unconventional platforms.


105. Combat medics serving at Role I are generally very familiar with TCCC principles. This is not reliably true for physicians, physician assistants, and nurses, since there is no DoD-wide requirement for them to receive this training. (BAF Role I – Combined Joint Special Operations Task Force)

106. Even Role I combat medical and non-medical personnel who are familiar with TCCC techniques and equipment may not receive up-to-date TCCC training and equipping prior to deployment. (Role I – 3rd Infantry Division, 1st Infantry Division, NSW, USMC/USN)

107. The current ARFORGEN cycle is not optimal for preparing medics for combat deployment.

There is too much turnover and new medic backfills will arrive just prior to deployment. It is not solely about medical skills. These new medics must integrate medical skills into unit TTPs and place in context of the mission in order to optimize performance and provide for a functional casualty response system. (Role I – 1st Cavalry Division, 1st Infantry Division, 3rd Infantry Division, 173rd ABCT)

108. Many physicians and physician assistants have limited training and experience in trauma care, especially pre-hospital trauma care. TCCC practices, interventions, and medications (fentanyl lozenges, ketamine, TXA, Hextend) are unfamiliar and/or seldom used by these providers. If they are not familiar with TCCC medications and technology, then they will not allow their enlisted medics to utilize them either. This is the primary reason we continue to see NS and LR being used for battlefield trauma resuscitation instead of Hextend. (Salerno Role I – 101st Airborne Division (AASLT) Physician Assistant)

109. There is no assurance that AF physicians will receive TCCC training. It is considered "elective" training even for deploying physicians and they are often not able to break away from clinic schedules to obtain TCCC training. Physicians deploying in support of combat operations need to know TCCC and to have trauma center rotations. (BAF Role I – USAF Senior PJ) 110. “Physicians don’t know battlefield trauma care.” (BAF Role I – USAF Senior PJ)

111. Senior medical leaders cannot force individual physicians to provide medical care that they do not agree with. (KAF Role I – 3rd Infantry Division) This underscores the need for physicians to be trained in TCCC and to be familiar with the evidence base for recommended TCCC interventions. (CoTCCC Chairman)

112. Many combatant unit physicians and physician assistants are not conducting combat missions with their units. Without this experience, it is difficult to understand the environment, ascertain requirements, and advance needed pre-hospital casualty care innovation and initiatives. (JTS Trauma Care Delivery Director)

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surgeon who is not invested downrange. Priority for medical training varies between divisions and between commanders at all levels. (Role I – 1st Infantry Division, 3rd Infantry Division)

114. Medics are currently the pre-hospital subject matter experts and center of gravity. Senior medics are the medical continuity for pre-hospital casualty response systems. (Role I – 75th Ranger Regiment) Army physician assistants used to share this role, but changes in their pathway over the past two decades have resulted in current variability for pre-hospital expertise.

(JTS Trauma Care Delivery Director)

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