Advances in Military Medic Training

The clattering of helicopter blades cuts through the humid air in a steamy jungle clearing behind enemy lines. On board an injured soldier lies on a stretcher with an IV dripping plasma into his arm. The pilot increases the pitch on the rotor blades and the helicopter rises on its slow journey to a U.S. Army hospital. This scene took place not in Vietnam but in Burma during World War II in 1945. It was one of the first times a helicopter was used to evacuate a wounded soldier from the battlefield.

Twenty years later, similar scenes occurred thousands of times during the Vietnam War. By then, dedicated U.S. Army air ambulance units, using the call sign Dustoff, had been established with the sole job of getting wounded soldiers to surgical hospitals as soon as possible. Almost 900,000 patients were transported by these units by the time U.S. involvement in the war ended. Since then, Dustoff units have accompanied U.S. troops in every major conflict. The success of their operations in Vietnam became the catalyst for the birth of the civilian air ambulance industry in the 1980s.

Army Flight Medic Training

While civilian air ambulances used highly trained nurses and paramedics, training for U.S. Army flight medics consisted of a NREMT EMT-Basic course with IV administration and advanced airway training. In addition, flight medics took Advanced Cardiac Life Support (ACLS), Pediatric Education for Prehospital Professionals (PEPP) and Prehospital Trauma Life Support (PHTLS).

When a unit returns to the U.S. after a tour of combat, they do an After Action Review (AAR) that lists positive and negative performance. AARs for medical units began to reflect the lack of critical care skills of the flight medics when treating and transporting very sick and severely injured patients. However, without definitive data, the Army would not act on this anecdotal evidence. Nothing was changed until one particular unit served in Afghanistan.

About two-thirds of all U.S. Army air ambulance units are in the Army National Guard or Reserve. Many of the flight medics in these units work as civilian paramedics for fire departments and ambulance services. In 2009, C Company, 1st Battalion of the 168th Aviation Regiment (C-1/168) was deployed to Afghanistan. It was an Army National Guard air ambulance unit with 12 UH-60 Black Hawk helicopters from California and Nevada, augmented with an additional three Black Hawks and crews from the Wyoming National Guard. Almost all of the flight medics were experienced civilian paramedics.

"Our unit developed its own set of protocols for the flight medics while we were being mobilized to go to Afghanistan," explains Steve Park, a former Army flight medic who deployed with C-1/168. At the time, Park was also a paramedic with the Regional EMS Authority in Reno, NV. Today he is a firefighter-paramedic with the North Lake Tahoe Fire Protection District in Nevada. "Our noncommissioned- officer-in-charge (NCOIC) of the flight medics, Rob Walters, a paramedic with the Sacramento (CA) Metropolitan Fire Department, developed them. They were pretty aggressive, with things like RSI and solumedrol for head injuries. Once in country, they had to be approved by the brigade flight surgeon who was in charge of all the flight medics. She was reluctant to allow this level of care, but Walters presented her with all of our certifications to show we could do this. We wanted to provide this level of care to our patients. We kept on saying that if every person in our home towns deserved paramedic-level care, our soldiers deserved that same level of care. We had to fight for it, and they finally gave us a trial period with our protocols. Once their staff saw what we were capable of, they allowed us to use our own protocols.

"We were really lucky in that one of our helicopter pilots was a pharmacist who also had some prehospital experience. Before we deployed, he taught several classes on some of the meds we were going to use and was available for any questions while we were deployed. "

"In Afghanistan, we were doing the traditional flight medic job but were also doing critical care transports from the Forward Surgical teams (FST) on 60-90 minute, or longer, flights with multiple medication drips. The FSTs had a couple of surgeons, a couple of nurses and a few operating room techs. The patients were usually flown out within hours of injury by helicopter to a Combat Support Hospital (CSH) in Bagram or Kandahar. The CSH was the Army equivalent of a Level 1 trauma center. The FSTs did the life-saving surgery to stabilize patients until they could get to the surgeons at the CSH."

In what would later become a key element to show the Army the benefit of paramedic-level training, the flight medics of C-1/168 developed a robust charting system.

"We all thought we wouldn't have to deal with charting in Afghanistan and would just do our medical care," Park says. "However, our NCOIC Rob Walters insisted upon good charting. We wanted to be able to do QI on our missions. We pulled together the best parts of several different charts to make one that met our requirements and conditions. It started out as a paper chart and then became electronic. One of our guys was really good with computers and was able to use an Army system to create an electronic patient care report (PCR). We would do chart reviews of medication usage, medical care, and difficult or challenging patients. It kept us honest. It also stayed in the patient's record so the receiving medical staff knew what care occurred en route."

The flight medics in Afghanistan were no longer just treating young soldiers with traumatic injuries. They were treating older contractors with health problems such as diabetes and heart attacks; sick and injured children and elderly civilians; and critically injured patients just out of surgery with multiple intravenous fluids and medications on ventilators. They were also transporting these patients over great distances and are caring for them for up to two hours.

Lt. Col. Robert Mabry, MD, was a battalion surgeon for a special forces battalion that was deployed to Afghanistan in 2005. "I was a paramedic before I became an doctor," Mabry says, "so I knew the level of care in civilian flight programs was very high. That planted a seed that I thought we needed to upgrade the training of the Army flight medics. I went to the doctors in charge of the Army flight medic program and they said there was no evidence there is anything wrong with what we were doing."

"I was told about an Army National Guard air ambulance unit that had mostly civilian paramedics for their flight medics. The unit was C-1/168. Using their patient care reports, I developed a study to show the outcome differences when the flight medics were also civilian paramedics. I looked at all the outcomes of the severely injured patients who arrived by helicopter at the large trauma hospitals in Bagram and Kandahar and their survival rate up to 48 hours."

"I compared the patient outcome for the air ambulance unit that served the year before C-1/168, while C-1/168 was in country, and the unit that served after C-1/168 rotated home. The study showed a 66% less chance of dying with the civilian paramedics of C-1/168. That is a big number. I expected maybe a 15% difference, not 66%. This gave the Army the data it needed to make a change in the training levels for flight medics."

Upgraded Training

The U.S. Army Medical Corps decided to upgrade the training of all current and new flight medics to NREMT-paramedic and add a critical care transport EMT-P course as well. The new training program began in 2012 and is broken down into three phases. Each phase corresponds to a civilian level of prehospital training using the U.S. Department of Transportation curriculum.

Phase 1 is five weeks at Fort Rucker, AL, home of U.S. Army aviation. The medic leaves as a certified Emergency Medical Technician-Basic. They use UH-60 Blackhawk trainers to practice their skills inside the vehicle they will be using. They also use a special tower for hoist training.

Phase 2 is the paramedic training. It is a 27-week course through the University of Texas Health Science Center (UTHSC) in San Antonio, TX. It includes 1,054 hours of training with 300–500 hours of clinical time with real patients. It is taught by civilian instructors.

Phase 3 is an eight-week critical care paramedic (CCP) course.. The curriculum is based on the University of Maryland Baltimore CCP program. It consists of three weeks of didactic training at UTHSC and five weeks of clinical time. The students do their clinical time either at UTHSC or Brooke Army Medical Center (BAMC). Rotations include the operating room for airway procedures, various intensive/critical care wards, the burn unit, cardiac catheterization lab, neonatal intensive care unit and pediatric intensive care unit, and obstetrics for delivering babies. This phase emphasizes development of critical thinking skills.

The final part of the CCP course integrates how medics fit into the military medical care system with the protocols they will use in theater for patient care. They also include a veterinarian clinic, since they will be caring for injured military working dogs.

The challenge for the Army flight medics versus civilian flight medics is the civilians usually have to have three to five years of ground ambulance paramedic experience in a high-volume system before they are accepted into a civilian flight paramedic program. The Army medics are going through the training programs back to back. The goal of the CCP section is to expose the Army flight medics to as many critical patients of all types as possible.

"We will ramp up to four classes per year," explains Sergeant First Class George Hildebrandt, Non-Commissioned Officer-In-Charge of the CCP program. "Our goal is to produce 232 flight medics per year going through all three phases of training. The National Guard has the largest need, since a majority of air ambulance units are in the Guard.

"The biggest challenge for the Guard personnel is to be away from their normal civilian career for 10 months for training. They will often be deployed immediately after the school for another year. So, they could be away from their home and job for two years. We have at least five National Guard and five Army Reserve slots in each course. The goal is to have all current flight medics upgraded by 2017. The Army plans to double the number of flight medics by 2017 to about 1,200."

The Home Station Training Program was established to allow units to send current flight medics to a local civilian paramedic training program to obtain the Phase 2 training. So far it is being used by units in South Dakota and Colorado. This is especially beneficial to National Guard units. The civil program must meet the Army standards and teach the program in the allotted 27-week time frame. The Army then pays for the tuition, fees and books for the program. The National Guard unit then puts the student on order so they get paid while going to school. There is an active duty unit that is sending 11 students through a program in Colorado. The local units find the programs themselves. It is a cost-effective way to train the soldiers and keeps them close to home for the longest phase of the training.

"Sustainment is the other side of this coin," states Mabry. "The first side is training. Once they are trained, we have to be able to keep their skills up. This is going to be one of the big challenges to this program. There are some units that are already making arrangements to train with local civilian air ambulance programs by riding with them on actual missions. In addition, the flight medics could work for civilian EMS agencies on their off-duty time to gain experience and make some extra money for themselves. A lot of the sustainment structure is still being designed.

"What I hope will happen is the Army develops some regional relationships with major medical centers so the flight medics will be able to do ongoing training without going too far from their home station. We also may bring them back to Fort Sam Houston every few years to update their training."

The Army is also looking at improving documentation as the new flight medics treat patients. The patient's chart will have all the care provided by the flight medics documented for medical personnel treating the patient hours or days later. It will also help with prehospital research projects, as well as provide quality assurance/quality improvement opportunities for the flight medics.

The U.S. Army Medical Evacuation Proponency Directorate at Fort Rucker, AL, is working on a standard set of Army-wide protocols that will be used by the new flight medics. The local units will have the ability to adjust these protocols based on local conditions and the skill set of the flight medics.

U.S. Army flight medics have a long history for caring for the sick and injured in some of the most difficult circumstances imaginable. The lessons learned from the wars in Iraq and Afghanistan have found their place in civilian emergency medicine, and advanced civilian prehospital care has found a place in the military.

HH-60M Black Hawk Helicopter

The UH-60 Black Hawk is the helicopter assigned to U.S. Army air ambulance units. The latest model is the HH-60M. The HH designates it as a special version with a medical interior and other additions to the standard Black Hawk airframe. The HH-60M is replacing earlier versions of the Black Hawk in air ambulance units. A total of over 350 are expected to be fielded. The basic M model has improved engines and rotor blades for a greater payload and better performance on hot days and at high altitudes. It also has what is known as a "glass" cockpit. This means the standard mechanical instruments have been replaced by four multi-function displays that look like computer screens. It has an embedded GPS system and a digital moving map display that shows where the helicopter is, as well as the terrain around the helicopter. The helicopter can cruise at 170 mph.

The HH air ambulance package adds a gimbaled pod with a Forward Looking InfraRed (FLIR) camera that "sees" the heat of objects. This can be useful at night and in poor visibility. The pod also contains a low light level camera. The main feature of the HH package is a medical interior in the cabin much like that found in a civilian air ambulance. It has six litter holders, three on each side of the cabin, with power lifts. The litters are arranged fore and aft. As a patient is loaded, the litter is lifted up so the next patient can be loaded. In addition to standard white lights, the cabin is equipped with night vision goggle compatible lights. There are also two main seats on tracks in the cabin for the crew that rotate 180 degrees.

Other features of the medical cabin:

• internal oxygen manufacturing system with three outlets on each side of the cabin
• Vacuum outlets for suctioning, three on each side of the cabin
• Impact Model 754 transport ventilator
• Zoll CCT cardiac monitor/defibrillator
• Propac Encore monitor
• three channel IV pump
• Independent cabin heating and air conditioning system
• System of soft packs on the walls to hold medical supplies
• Assortment of splints and other gear found in any ambulance

Extended Interview with Former Staff Sergeant Steve Park, U.S. Army Flight Medic

"When we deployed, our unit supplied the Army air ambulances for all of Afghanistan. The helicopters were split into detachments at Kandahar, Bagram and a three helicopter unit at a Forward Surgical Team (FST) at a Forward Operating Base (FOB) near the Pakistan border. The helicopters based out of Kandahar and Bagram were rotated to the FOBs. Often these were single ship detachments. We had to have escorts, which might be Army or Marine gunships. The crews would rotate every 1 to 2 weeks back to the main base. I was stationed several times at Camp Bastion with the U.S. Marines. There were no hard structures really, we were living out of tents.

"There were two combat support hospitals (CSH), which were equal to a level 1 trauma center, one in Bagram and one in Kandahar. The receiving facility for a transport from the site of the injury, basically a scene call, depended on the location of the patient. When I was working out of Bastion, we would return the patients there which had a British medical unit that had a higher level of care than an FST.

"The FSTs had a couple of surgeons, a couple of nurses, a few OR techs. The patients were usually flown out within hours of injury by helicopter to a CSH. Many times I was waiting for the patient to come out of surgery, get a report from the surgeon, and then load them on my helicopter. The FSTs did the lifesaving surgery to stabilize them until they could get to the surgeons at the CSH.

"Afghanistan was a different kind of battlefield from the standpoint of medicine. Up until then, the traditional flight medic training worked well. A short flight with an injured soldier who might need bleeding control, fluids and possibly some airway control. In Afghanistan, we were doing the traditional flight medic job, but also taking critical care transports from the FST on 60–90 minute or longer flights with multiple medication drips. We sometimes had more drips running than we had pump channels. So, we had to work with the doctors and nurses at the FST to figure things out. We might discontinue a drip and bolus the patient with certain medications because we only had one three-channel pump.

"We would also do what we called tail-to-tail flights. To keep helicopters available and close to their response areas, we might meet another ship halfway between their FOB and the CSH and land at a secure site and transfer the patient from one helicopter to another.

"The traditional crew of a medevac helicopter is two pilots, a crew chief and flight medic. Our partners in the back were the crew chiefs. They were amazing in the way they helped us with patient care. We trained them to assist us. We also helped them out as much as we could with basic maintenance of the helicopter, which was their job. In combat, everybody works to achieve the unit goal of taking the best care of our soldiers, so we were never truly by ourselves in the cabin with the patients. If we knew we were going on a really serious mission, maybe with multiple patients, we would grab another flight medic.

"We used a Zoll CCT monitor-defibrillator, a Propac Encore monitor, one three channel IV pump, an Eagle Vent ventilator, a first-out bag oriented toward trauma, basically everything you would find in a civilian paramedic ambulance. Most flight medics wore a leg bag with tourniquets, a cric kit and other airway equipment. We mostly did intubations with the King Airway as a rescue backup. We used bottled oxygen. Some helicopters had an oxygen generation system, but they never seemed to work well. We had a system of bags that hung on the walls of the cabin to hold gear to keep the floor clear for patients.

"We had a very diverse selection of patients. They weren't just young, healthy soldiers with traumatic injuries. We had pediatric and geriatric Afghani civilians, as well as American civilian contractors with a wide variety of health problems. This is another area where our civilian paramedic experience helped us tremendously. We had pediatric burn patients and trauma patients with landmine injuries. There are millions of landmines in Afghanistan that go back 50 years or more. We were able to do 12-lead ECGs and interpret them. I had a STEMI patient that was an older civilian contractor.

"Endtidal CO₂ was a big help with our intubated patients. You can't really hear lung sounds in the back of a Black Hawk helicopter. That was a big challenge for us as paramedics, not being able to listen to lung sounds or even talk with our patients because of the noise level. I carried a small white board so I could communicate with my patients. We sometimes put a headset on the patient so we could talk with them. We had to figure workarounds to these problems.

"With our Afghani patients, we often couldn't communicate with them at all due to the language barrier. We also had to be sensitive to their cultural beliefs, especially with female patients. I would say that 40%–50% of our patients were Afghani. It was a huge challenge.

Park was working for the Regional EMS Authority (REMSA) in Reno, Nevada, when he deployed to Afghanistan in 2009. He would occasionally send an e-mail to the employees to let them know what it was like to work as a flight medic in a war zone. The following is an excerpt from one of those emails:

Saturday-May 2, 2009

Hi everyone,

I wish I could report that things were slow, but that's not the case. We have been running about 4–6 calls a day here at Bagram and averaging 1.5 to 2 hours per flight with almost all of the calls trauma related as I'm sure you can imagine. IED injuries and neuro trauma seem to be the most common, with a large portion being pediatrics. The ground to air threat seems to be increasing too as we have been shot at several times and our flares (defense systems) go off on almost every flight, which scares the hell out of you even if you're expecting it.

We had a point of injury (scene) call the other day where we had to do a two wheel landing at the crest of a mountain. The patient was shot in the chest and during the patient extraction our escort helicopter took small arms fire and damage from an RPG (rocket propelled grenade). We had another call where we were talking with our Apache gunship escort, getting ready to land, when an F-15 fighter-bomber circling above ordered everyone to clear the area as they saw some bad guys doing some bad things in the area we were going and dropped a bomb on them, which was pretty cool and nice to know we were being watched over.

For the most part, things are going very well although I think most of us are ready to come home and get on with our lives. I personally have seen enough trauma to last a lifetime. I am learning tons everyday and the experiences here are unforgettable. Just like back home, some calls affect you more than others, but here the brutal reality of war is an everyday occurrence. Here are a few things that we should never have to do:

• place tourniquets on the legs of children who are bleeding out from massive trauma caused by IED/landmines
• stack multiple kids on litters because there isn't enough room on the helicopter for all of them otherwise
• needle decompress kids multiple times
• see the lungs of kids through the holes in their chest
• run out of tourniquets on one call
• change uniforms multiple times in one day due to being saturated with blood
• wish the next call is a normal trauma with only one patient
• spend two hours cleaning the blood out of your aircraft

Thanks for listening,

Steve Park