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.