MEDEVAC Proponency / By Mr. George W. Hildebrandt: The Army’s ability to provide pre-hospital critical care and trauma treatment on battlefield aeromedical evacuation platforms has evolved dramatically since 2012. In 2011, the Defense Health Board (now called the Defense Health Agency) published a memorandum documenting that U.S. Army flight medics lacked the appropriate skill level and training to properly treat trauma casualties evacuated off the battlefield. Prior to 2012, flight medics were Emergency Medical Technician (EMT)-Basic certified; since that time, the Army developed the Critical Care Flight Paramedic (CCFP) Program in response to emerging data from combat operations. That data revealed that 87% of all battlefield deaths occurred in the prehospital environment and approximately 25% of those deaths were potentially survivable if optimal care had been provided to the patient at the point of injury and during evacuation to the medical treatment facility.
SSG James Shields from 6th Battalion, 101st Combat Aviation Brigade, prepares to give an intravenous infusion to an injured Afghanistan National Army Soldier. / U.S. ARMY MEPD COURTESY PHOTOS
Training and Certification
Currently, the CCFP Program is in full swing, training and certifying up to 208 students each fiscal year to the National Registry Paramedic (NRP) standard. In addition to paramedic certification, flight paramedics receive eight weeks of critical care training in order to provide them the medical skills required to treat and evacuate trauma and post-surgical patients between roles of care on the battlefield. The five weeks of clinical rotations during the critical care training course provide the CCFP with the hands on experience necessary to perform enroute care on our most severely wounded warriors. The CCFP students also attend the AMEDD Aviation Non-Rated Crewmember Course at the School of Aviation Medicine (USASAM) for five weeks which focuses on the basics of Army Aviation with an emphasis on the Army aircrew program and operationalizing medical skills in the airframe. The aeromedical training focuses on aircrew coordination, aviation safety, aviation life support equipment, water survival, and aircrew training for the H-60 series helicopter. The students use state-of-the-art high fidelity simulators to replicate treatment in and around the helicopter during both day and night operations, perform high performance rescue hoist operations, and learn aeromedical evacuation principles, practices, and doctrine using the Standard Medical Operating Guidelines (SMOG). In order to sustain and recertify the flight paramedic and critical care skill sets obtained during the CCFP program, new programs have also been developed by the CCFP Program Office and Army EMS to ensure the flight paramedic has the ability to maintain, sustain, and recertify their certificates.
A two-week recertification course was developed at Joint Base San Antonio (JBSA), Texas which provides the CCFP all 72 continuing education units (CEUs) required bi-annually for recertifying the NRP certificate. It also provides refresher training on critical care skills in addition to the CEUs for the flight paramedic certification. In order to meet the training requirements of the CCFP, an Army-level medical training publication is being created by the CCFP Program Office and Army EMS Office to outline certification, sustainment, and proficiency requirements. Training Circular 8-800 is currently being utilized to sustain the 68W qualification but does not fully address the critical care portion of the CCFP. To meet some of the shortfalls in training, several air ambulance companies have been utilizing Medical Simulation Training Centers (MSTC) on or near their installations. The MSTC provides training and evaluation of Table VIII annual requirements for the 68W, to include the NRP. During the most recent capability development document review for the MSTC, it was noted that “exportable and transportable” simulation training packages are required for air ambulance units that cannot access or utilize the MSTC for training due to lack of TDY funding, deployments, OPTEMPO, and/or geographic challenges. The new “exportable and transportable” simulation training module will provide realistic medical training through the use of high-fidelity patient simulators and other approved medical equipment. The advantage of “exportable and transportable” simulation devices is that they can be utilized on board the helicopter with an air worthiness release while deployed or at home station for realistic sustainment and proficiency training.
An enroute critical care provider double checks the patient and medical interventions while performing a critical care patient transfer mission.
The CCFP Home Station Training (HST) program has been a great tool for the National Guard Bureau (NGB) to meet most of their training requirements. Originally approved in 2012, CCFP HST provides air ambulance units from all components additional flexibility to send Soldiers to paramedic and critical care courses offered in the civilian community if they meet the specific standards set forth by the CCFP Program Office. In the last six months, the NGB received over $3.1 million in additional funds to support CCFP training which has allowed them to not only fill all authorized ATRRS seats at the JBSA course for FY16/17, but also take advantage of the HST option. The CCFP Program Office has also approved several critical care courses based on curriculum and clinical experience to meet the CCFP standard.
Standard Medical Operating Guidelines
Due to the critical nature of training and sustaining the CCFP skill set, additional products for CCFP management have been published to provide commanders and flight surgeons (medical directors) with the appropriate tools necessary to utilize CCFPs to their full capability. The Standard Medical Operating Guidelines (SMOG) are the only centralized and standardized set of flight paramedic protocols employed by the CCFP. These guidelines were developed by a team of Emergency Medical Service (EMS) professionals, experienced flight medics/paramedics, aeromedical physician assistants, and flight surgeons and were endorsed by the Aeromedical Consultant to the Surgeon General. The purpose of the SMOG is to enhance and standardize enroute care by providing the CCFP with the most current protocols and treatment practices across all Army Air Ambulance Units. While the SMOG is intended primarily for the CCFP, it also serves as a reference for physicians and flight surgeons providing medical direction and clinical oversight. The SMOG is updated annually by a multidisciplinary team of medical professionals who have experience in both combat and garrison prehospital medicine environments. In addition to the standard medical treatment protocols, the SMOG contains the most recent battlefield-proven treatments, including treatment for military working dogs and onboard blood transfusion treatment and management. DoD Joint Trauma Registry analysis shows that the rapid transfusion of blood and blood products is one of the best possible treatments for trauma-associated hemorrhage which is one of the leading causes of death to injured Soldiers on the battlefield. Since 2012, over 345 patients have received transfused blood or blood products during evacuation in combat operations.
Today, the Critical Care Flight Paramedic has the knowledge and skills to provide outstanding enroute care to wounded Soldiers, comparable to the best U.S.-based civilian air ambulances; however, without the appropriate medical equipment and workspace, this increased CCFP skillset cannot be completely exploited. This conclusion was supported by the recent findings in three key efforts: the 2015 Aeromedical Evacuation Enroute Critical Care Validation Study (i.e., “Cabin Space Study”), the 2016 MEDEVAC Mission Systems Capability Based Assessment (CBA), and the 2016 Patient Handling System (PHS) Crew Station Working Group. The aforementioned efforts identified a number of shortfalls associated with the current MEDEVAC Blackhawk’s PHS which included: excessive weight, inability to adjust in flight, suitability to perform advanced critical care tasks, and the need for 28 inches of vertical space between litter pans to conduct required treatment. In order to mitigate these gaps, PD MEDEVAC, in concert with the Medical Evacuation Proponency Division (MEPD), are improving the current Basic Medical Interior of the HH-60M and the Interim Medical Mission Support System (IMMSS) of the UH-60A/L and are conducting analysis and research in order to develop an improved PHS to be designed for Critical Care on current and future MEDEVAC platforms.
The Critical Care Flight Paramedic Program has proven extremely successful since its inception 5 years ago. The new CCFP performs initial treatment and enroute care at a much higher level than previous EMT-Basic certified flight medics and is saving more lives on the battlefield today and also providing improved care for every Soldier evacuated. The CCFP Program has contributed to achieving a hostile action survivability rate of 91.6% during Operation Enduring Freedom; this is the highest hostile action survivability rate in the history of U.S. conflicts. Currently, if you are a U.S. or Coalition casualty on the battlefield of Afghanistan and you arrive alive to a Role 3 Medical Treatment Facility (MTF), your chance of survival is greater than 98%. The CCFP has clearly been identified as the appropriate skill level for the treatment of casualties during evacuation on aeromedical platforms. The success of the CCFP has spurred the Army Medical Department to look at closing the gap between the EMT-Basic Ground Combat Medic and the Critical Care Flight Paramedic under the “Enhanced Medic” Program initiative.
Army Medicine is ever changing, but the requirement to provide the best care to the United States’ and our allies’ most precious asset, its Soldiers, has not. Army medicine will continue to strive for the best training, equipment, and resources for our Soldiers to meet that requirement.
Mr. George W. Hildebrandt is the Flight Medic subject matter expert (SME) for the U.S. Army Medical Evacuation Proponency Directorate (MEPD) at Fort Rucker, AL.