i n t e g r i t y - s e r v i c e - e x c e l l e n c e 122 nd mdg 48r – rsv training brian j....

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

122nd MDG

48R – RSV TrainingBrian J. Dykstra, Col, SFS, INANG

AE Overview

Indiana Air National Guard

Disclaimer

• The content is mine and not official DoD, USAF, or ANG doctrine/policy

• I used notes and pictures from other sources on the Kx exchange as well as the internet

• I have been deployed as a CCATT doc in Balad 2007, Bagram 2008, Ramstein 2011, and as a SME in Bagram/Kuwait 2014-15 (while deployed as a SME I flew a number of AE missions on C130s), March ‘15 I flew the weekly PACAF AE mission

• I have no commercial relationships or any conflicts of interest


Objectives

• RSV Training for AEo Medical Clearance for AE (perform 5); suitable substitute if unable

to perform clearances: Read relevant sections of Flight Surgeon’s Guide and SGP Tactics Guide

• AE Overviewo Medical / Flight Surgeon concerns and responsibilities for AE and

AE patient processingo What is AEo Capabilities of AEo Process of AEo Definitions/Acronyms


AE Definition

• AE is the movement of patients under medical supervision to and between medical treatment facilities by air transportationo AE specifically refers to United States Air Force evacuation

movement of regulated casualties, using organic airframes, with AE aircrew specifically trained for this mission

• Capabilitieso Integrated control of casualty movement by air transporto Clinical & Ops support personnel to complete the missiono Inflight and ground support personnel; equipmento En route staging capability (ERPSS): ASF/MASF/CASF


Guidance

• Some Regs:o AFPD 10-29, World Wide AE Ops – Establishes policy and assigns

responsibilities for AE Opso AFI 41-307o AFI 10-2912 o AFTTP 3-42.5


Basic Movement Process

• Point of Injury (POI)• CASEVAC to 1st MTF/CSF then MEDEVAC to ASF• At ASF PMR (Patient Movement Request) placed into TRAC2ES

(TRANSCOM Regulating Command & Control Evacuation System) to move patient AEROVAC

• Request vs Requiremento Physicians at originating or accepting facilities submit requests for

movement, timing, destinationo Validating Flight Surgeon and PMRC validate those requests into

airlift “requirements”


Basic Movement Process Con’t

• Validation by FS (VFS) occurs at PMRC (Patient Movement Requirement Center)

• VFS brings medical leadership and decision making to the process of prioritizing use of aviation assetso 1st question VFS asks is whether patient should fly at all

• Validation vs Clearanceo Clearance to move by air is done at the MTF, i.e. is patient stable

for flighto Validation for AE, located at PMRCo AE clearance is a medical care event; validation is a logistic, not a

medical event


Basic Movement Process Con’t

• Transformation from a request into airlift requirement: the Patient Movement Clinical Coordinator (PMCC) at the PMRC obtains necessary clinical data and medical equipment requirements from attending physician prior to manifesting patient for movement

• PMRC provides medical regulating and AE scheduling for transport to next higher level of careo AE airlift planners of AE Control Team (AECT) w/in Air Mobility

Division (AMD) of the Air Operations Center (AOC) recognize and respond only to validated requirements

o AE airlift planners work closely w/ the PMRC in coordination

• AOC identifies and tasks aircraft and resources


FS Responsibilities

• Local clearance authority, i.e. is patient physiologically ready for air travel & Category (urgent, priority, routine)

• May fly as medical attendant (MA) if necessary• If at an ASF (Aeromedical Staging Facility): Evaluates/manages

patients• Interacts w/ originating physician by defining level of care & care

plan en routeo Assess appropriateness of AEo Ensure patient stability / stabilized (if CCATT required)

• Assess movement precedence – determine priority• Works closely with VFS• Begins/completes the 3899 - PMR


FS Responsibilities

• Clearing FS must consider:o Ability to travel vs need for definitive careo Flight schedules and prep timeo Travel time, including possible stops

Some flights around the AOR make multiple stopso Medical capabilities/resources at any stopso Attendant (medical/non-med) qualifications


3899 - PMR


Patient Precedence (Priority)

• Urgento Temporarily “stabilized”o Goal: movement w/n 12 hourso Life, limb, eyesighto ISS – In-system select (cargo mission disrupted to support AE

mission)o Most likely needs CCATT

• Priorityo Stabilizedo w/n 24 hours, can’t wait for next scheduled flight, may be ISS

• Routineo Stable, capable of waiting up to 72 hrs on next scheduled mission


Fixed Wing Options


Stresses of Flight

• Altitude/Decreased PaO2• Barometric pressure changes• Thermal changes (especially KC135s and C130s)• Decreased humidity• Noise• Vibration• Fatigue• Gravitational Forces• Long days


Altitude Restriction

• Altitude restriction requires lower flight level which can lead to:o Increased fuel consumption – enough fuel for mission/flighto Lower altitude decreases speed and increases flight timeo May increase turbulence due to weather


Altitude / Hypoxia

• Does the patient prior to flight need supplemental oxygen?• Will the patient during flight need supplemental oxygen?• What is the Hgb?

o If Hgb <8mg/dL, can only transport if anemia is chronic & stable and not related to bleeding, if Hct <25% need VFS concurrence

• Chronic low Hgbo 8.5-10mg – O2 available

o 7.0-8.5mg – O2 at 2L for flighto <7.0mg – AE VFS approval

• Post-Op anemiao 9.0-10mg – O2 available

o 8.0-9.0mg – O2 at 2L for flighto <8.0mg – AE VFS approval


Humidity & Temperature

• At altitude, the air is much drier which can affect pulmonary secretionso O2 needs bubblero Vented patients need the HME

• C130 & KC135’s are very difficult with temperature controlo Significant temperature difference between the top and bottom of

the cabin

• Also consider temperature during transport to and from plane


Barometric Pressure

• Complications of increased pressure/volume in body cavitieso Abdominal surgery

Abdominal compartment syndrome Respiratory embarrassment pushing up on the diaphragm Decreased blood return to the chest leading to decreased cardiac output

due to compression of great vessels in abdomen and increased intrathoracic pressure

Ostomy bags – need to vent collection bagso Chest

Pneumothorax – Need a Heimlich valveo Pain may increase – sinuses, ear drums

• ET & Tracheostomy tubes – check cuff at altitude and then upon landing

• Eye/Globe injuries – air in the globe


Vibration

• Ortho patientso Fractureso External Fixators

• Other injuries & surgeries• Increases muscle fatigue to maintain balance

o May result in increased lactate due to muscular use which can then increase need for minute ventilation – is the patient capable to meet this demand for increased ventilation


G-Forces

• For most part not a big deal• G-forces are primarily applicable to the neuro patients• Different planes fly at a different angle of attack at cruise• Generally keep head forward facing


Noise

• Increases stress & fatigue• Difficult to communicate – both from patient to AE crew and

amongst AE crew• Make sure patients have ear protection, especially important for

those who can’t insert the foamies


Fatigue

• Due to the overall stresses of flight, even if patient is relatively stable the stresses of flight can lead to increased fatigueo Noiseo Vibrationo Temperature changeso Low humidityo Long dayo Long flight


AE Process

• Originating MTF determines requirement for AEo MRO/PAD requests patient AE to AELT and PMRC

• AELT (AE Liaison Team)o Communicates pt movement requirementso Confirms pt prep

• PMRC (Patient Movement Requirement Center)o Validates clinically & administrativelyo Determines destinations optionso Determines appropriate componento Produces Lift and Bed Plan b/t originating & destination MTV


Contingency AE Structure


Process Con’t

• JFACC (Joint Forces Air Component Commander)o AOC/AECT

Identifies resources Collaborates w/ PMRC Decides appropriate airframe Send ATO to AEW

• AEWo Receives ATO, tasks aircrew, launches aircraft to on-load airfield

• MASFo Stages pt for evac, supports pt careo Loads pt on aircraft, briefs AE crew on pt loado Notifies AELT, AMD/AECT of departure


AE System Components

• AE Squadrono C2o AECMs (AE Crew Mbrs)o AELT (AE Liaison Teams)o AEOT (AE Operations Teams)o AE Support Cello AECT (AE Control Team)o AEOC (AE Operations Center)

• Ground Medical/MTFso Support Equipmento Specialized Equipmento ERPSS (En Route Patient Staging System)


AE Squadron

• C2o Manpower: 8o AFMS officer cmd assigned to OG of the AMW

• AECMso Basic: 2FN & 3AETs (AE Techs); but can be augmentedo Requires AEOT support of mission launch, recovery, management,

supporto Directed by AOC in control of the airlift mission

• AELTo Manpower: 2o Immediate coordination b/t user service & USAF AE Systemo Highly mobile; embedded


AE Squadron

• AEOTo Manpower: 8o Operational & mission management support to airfields conducting

AE opso Crew scheduling/mgt for AE crews & CCATTso Coordinates support requirements, aircraft configuration, logistics

& support, ramp operations

• AE Support Cello Manpower: 4o Admin, logistical, AGE maintenance, Comms


AE Squadron

• AECTo Medical personnel trained in AE command & control attached w/n

the AMD of the AOCo Responsible for:

Ops planning Scheduling Tasking Execution Monitoring in coordination w/ air mobility controllers Coordinates w/ the J-4 medical branch on the JTF staff and the PMRC

on patient movement requirements and priorities

Indiana Air National Guard 32

Patient Movement Process


Patient Classification

• 1 – Psycho 1A – severely ill, requiring close supervision: sedated, restrained,

on a dressed littero 1B – mod to severely ill: sedated, litter, restraints availableo 1C – cooperative, reliable, mod severe psych inpatient traveling

ambulatory status

• Litter categorieso 2A – who may or cannot ambulate and may be unable to perform

self care, requires assistance in event of emergencyo 2B – able to ambulate and sit in a seat, should be able to ambulate

in event of an emergency


Patient Classifications con’t

• Ambulatory categorieso 3A – Inpatient, non-psych, requirement medical treatment, assistance or

observation en route (usually minimal), or returning from inpatient visit at a MTF

o 3B – Recovering inpatient, returning to home station, requires no medical attention en route

o 3C – Ambulatory drug or alcohol substance abuse inpatient going for treatment

• Infant categories: 4A – E• Outpatient categories: 5A-F• Attendant categories

o 6A – medical attendant (physician, nurse, tech)o 6B – non-medical attendant


QUESTIONS

i n t e g r i t y - s e r v i c e - e x c e l l e n c e 122 nd mdg 48r – rsv training brian j....

Documents

air operations

air transportationae

ae aircrew

ae forces

air force ae crew members

medical aircrew

regulated air transport

medical supervision