Emergency War Surgery (2004)

Emergency War Surgery

Mechanisms of Injury (Fig. 1-9)

Ballistic injuries take place as the result of defeated armor as

described above.

A Translational blast

Blast overpressure

injury

Toxic gases

Missiles

Fig. 1-9. Injuries sustained as a result of defeated armor, (a) translational

blast injury, (b) toxic gases, (c) blast overpressure, (d) penetrating

missile wounds.

Thermal. Burns occur because of ignited fuel, ammunition,

hydraulic fluid, or as the direct result of the antiarmor device.

ο Two large studies, one from British WWII tank crewmen

and one from Israeli casualties in Lebanon, showed that

about ¹⁄3 of living wounded casualties have burns.

1.12

Weapons Effects and Parachute Injuries

ο The severity of burns range from a mild 1^st degree burn to

full thickness burns requiring skin coverage. Most burns

are superficial burns to exposed skin, most often of the

face, neck, forearms, and hands. These are often combined

with multiple fragment wounds.

Blast overpressure occurs from the explosion occurring

inside a confined space. One study from WWII showed 31%

of armored crewmen casualties had ear injury due to blast

overpressure, including ruptured tympanic membranes.

Toxic Fumes are secondary to phosgene-like combustion

byproducts in Teflon coated interiors of armored vehicles

(antispall liners).

ο HCL is produced at the mucous membrane.

ο Treatment is supportive and may require IV steroids (1,000

mg methylprednisolone, single dose).

ο Surgical triage considerations. Emergent if pulmonary

edema, expectant if hypotensive and cyanotic. Reevaluate

nonemergent patients q 2 h.

Blunt Trauma is due to acceleration mechanisms.

Unexploded Ordnance (UXO)

UXOs are embedded in the casualty without exploding.

ο Rockets, grenades, mortar rounds.

ο Some UXO must travel a distance (50-70 m) in order to arm.

ο Fuses are triggered by different stimuli (impact,

electromagnetic, laser).

Notify explosive ordnance disposal immediately!

³¹⁄31 victims lived after removal (from recent review).

The casualty should be triaged as nonemergent, placed far

from others, and operated on last.

Preplan for how to handle both transport and operation.

ο Transport.

♦ If by helicopter, ground the casualty to the aircraft

(there is a large electrostatic charge from rotors).

ο Move into safe area.

♦ Revetment, parking lot, or back of building.

ο Operate in safe area, not in main OR area.

Operative management.

ο Precautions for surgeon and staff.

1.13

Emergency War Surgery

♦ Sandbag operative area, use flak vests and eye protection.

ο Avoid triggering stimuli.

♦ Electromagnetic (no defibrillator, monitors, Bovie

cauterizer, blood warmers, or ultrasound or CT

machines).

♦ Metal to metal.

♦ Plain radiography is safe. It helps identify the type of

ammunition.

ο Anesthesia.

♦ Regional/spinal/local preferred.

♦ Keep oxygen out of OR.

♦ Have anesthesiologist leave after induction.

ο Operation: The surgeon should be alone with the patient.

♦ Employ gentle technique.

♦ Avoid excessive manipulation.

♦ Consider amputation if other methods fail.

♦ Remove en-bloc if possible.

The decision to remove a chemical/biological UXO is a

command decision.

Immediately after removal, hand to explosive ordnance

disposal (EOD) personnel for disposal.

Parachute Injuries

Dependent on several factors: Weather (wind), day/night,

drop zone hazards/terrain, low drop altitude, and level of

opposition (enemy resistance) at the drop zone.

Caused by improper aircraft exit, parachute malfunction,

hazards (including enemy) on descent or in the landing zone,

entanglements, or an improper parachute landing fall (PLF).

Peacetime rate of injuries is 0.8%.

Combat injury rate is historically higher (subject to above

listed factors).

ο As high as 30% overall.

ο Majority of injuries are minor.

ο 8% to 10% of total jumpers are rendered either combat

ineffective or significantly limited.

1.14

Weapons Effects and Parachute Injuries

Injury Site/Type

Ankle

Sprain/Strains

37.7

Back

11.1

Contusions

30.1

Knee

10.7

Lacerations

14.7

Head/Neck

8.7

Closed Fractures

11.1

Leg

8.3

Concussions

2.0

Open Fractures

2.0

—

Fractures result in a higher percentage of removal from

combat.

Fractures of the calcaneus are associated with fractures of

the axial skeleton (10%). Patients should be placed on spinal

precautions until such injuries are ruled out.

1.15

Chapter 2

Levels of Medical Care

Military doctrine supports an integrated health services support

system to triage, treat, evacuate, and return soldiers to duty in

the most time efficient manner. It begins with the soldier on the

battlefield and ends in hospitals located within the continental

United States (CONUS). Care begins with first aid (self-aid/

buddy aid, and combat lifesaver), rapidly progresses through

emergency medical care (EMT) and advanced trauma manage-

ment (ATM) to stabilizing surgery, and is followed by critical

care transport to a level where more sophisticated treatment

can be rendered.

There are five levels of care (also known as “roles”), previously

referred to as echelons by NATO and ABCA (USA, Britain,

Canada, Australia) countries. Levels should not to be confused

with American College of Surgeons use of the term in US

trauma centers. Different levels denote differences in capability,

rather than the quality of care. Each level has the capability of

the level forward of it and expands on that capability. Soldiers

with minor injuries can be returned to duty after simple

treatments at forward locations, all others are prepared for

evacuation with medical care while en route to a higher level.

Level I

Immediate first aid delivered at the scene.

ο First aid and immediate life-saving measures provided by

self-aid, buddy aid, or a combat lifesaver (nonmedical

team/squad member trained in enhanced first aid).

ο Care by the trauma specialist (91W) (combat medic),

assigned to the medical platoon, trained as an Emergency

Medical Technician-Basic (EMT-B). Some other primary

2.1

Emergency War Surgery

care providers, with various levels of training, include the

Special Forces Medical Sergeant 18D, Special Operations

Combat Medic 91W, SEAL Independent Duty Corpsman,

Special Boat Corpsman, Pararescueman, and Special

Operations Medical Technician.

ο Initial treatment of nuclear, biological, and chemical

casualties, treatment of toxic industrial material casualties,

primary disease prevention, combat stress control

measures, and nonbattle injury prevention.

Level I medical treatment facility (MTF) (commonly referred

to as the Battalion Aid Station [BAS]).

ο Provides triage, treatment, and evacuation.

ο Physician, Physician Assistant (PA), and medics.

ο Return to duty, or stabilize and evacuate to the next level.

ο Can be chem/bio protected.

ο No surgical or patient holding capability.

US Marine Corps (USMC): Shock Trauma Platoon (STP).

ο Small forward unit supports the Marine Expeditionary

Force (MEF).

ο Stabilization and collecting/clearing companies.

ο 2 physicians.

ο No surgical capability.

ο Patient holding time limited to 3 hours.

Level II

Increased medical capability and limited inpatient bed space.

Includes basic primary care, optometry, combat operational

stress control and mental health, dental, laboratory, surgical

(when augmented) and X-ray capability.

100% mobile.

Each service has a slightly different unit at this level.

Army.

ο Level II MTFs operated by the treatment platoon of

divisional/nondivisional medical companies/troops.

♦ Basic/emergency treatment is continued.

♦ Packed RBCs (Type 0, Rh positive and negative), limited

X-ray, laboratory, and dental.

♦ 20-40 cots with 72-hour holding.

2.2

Levels of Medical Care

♦ Can be chem/bio protected.

♦ No surgical capability.

Forward Surgical Team (FST).

♦ Continuous operations for up to 72 hours.

♦ Life-saving resuscitative surgery, including general,

orthopedic, and limited neurosurgical procedures.

♦

20-person team with 1 orthopedic and 3 general

surgeons, 2 nurse anesthetists, critical care nurses and

technicians.

♦ The supporting medical company must provide

logistical support and security. (Doctrinally, the FST is

collocated with a Medical Company.)

♦ ~1,000 sq ft surgical area.

♦ Can be chem/bio protected.

♦ Operational within 1 hour of arrival at the supported

company.

♦ May be transported by ground, fixed wing, or helicopter;

some fleet surgical teams (FSTs) are airborne deployable.

♦

2 operating tables for a maximum of 10 cases per day

and for a total of 30 operations within 72 hours.

♦ Post-op intensive care for up to 8 patients for up to 6

hours.

♦ X-ray, laboratory, and patient administrative support

provided by the supporting medical company.

♦ Requires additional electricity, water, and fuel from the

supporting medical company.

♦ The FST is not designed, staffed, or equipped for stand

alone operations or conducting sick-call operations.

Augmentation requirements are discussed in FM 4-02.25.

Air Force.

ο Mobile Field Surgical Team (MFST).

♦ 5-person team (general surgeon, orthopedist, anesthetist,

emergency medicine physician, and OR nurse/tech).

♦ 10 life/limb saving procedures in 24-48 hours from five

backpacks (350 lb total gear).

♦ Designed to augment an aid station or flight line clinic.

♦ Not stand alone, requires water, shelter of opportunity,

communications, among other things.

2.3

Emergency War Surgery

♦ Integral to remainder of Air Force (AF) Theater Hospital

System.

Small Portable Expeditionary Aeromedical Rapid

Response (SPEARR) team.

♦ 10-person team: 5-person MFST, 3-person CCATT (see

Chapter 4, Aeromedical Evacuation) and a 2-person

preventive medicine (PM) team (flight surgeon, public

health officer).

♦ Stand alone capable for 7 days, 600 sq ft tent.

♦ 10 life/limb saving procedures in 24-48 hours.

♦ Designed to provide surgical support, basic primary

care, post-op critical care, and PM for early phase of

deployment.

♦ Highly mobile unit, with all equipment fitting in a one-

pallet-sized trailer.

Expeditionary Medical Support (EMEDS) Basic.

♦ Medical and surgical support for an airbase, providing

24-hour sick call capability, resuscitative surgery, dental

care, limited laboratory and X-ray capability.

♦ 25 member staff includes SPEARR team.

♦ 4 holding beds, 1 OR table, 3 climate controlled tents,

and 3 pallets.

♦ 10 life/limb saving procedures in 24-48 hours.

♦ ~2,000 sq ft.

EMEDS + 10.

♦ Adds 6 beds to EMEDS Basic, for total of 10.

♦ No additional surgical capability.

♦ 56-person staff.

♦ 6 tents, 14 pallets.

♦ Can be chemically hardened.

Navy.

ο Casualty Receiving & Treatment Ships (CRTS). CRTSs

are part of an Amphibious Ready Group (ARG) and

usually comprise one landing helicopter assault or

amphibious (LHA) Tarawa-class or landing helicopter deck

(LHD) Wasp-class ship, which are Marine amphibious

2.4

Levels of Medical Care

assault helicopter carriers that function as casualty

receiving platforms. An ARG includes up to 6 ships with

surgical capability only on the CRTS.

♦ 47-48 beds, 4-6 ORs, 17 ICU beds.

♦ 300 additional medical care beds may be available once

Marines diseembark.

♦ Fleet Surgical Teams (FSTs): 3-4 physicians, 1 surgeon,

1 CRNA or anesthesiologist and support staff.

♦ Usually 2 general surgeons and 2 orthopedic surgeons.

OMFS (oral maxillofacial surgery) support available

through the dental department. Can be substantially

augmented.

♦ Laboratory, X-ray.

♦ Excellent casualty flow capability (large helicopter flight

deck and landing craft units [LCU] well deck).

♦ Mass casualty (MASCAL) capability with triage area

for 50 casualties.

♦ Doctrinally, holding capability is limited to 3 days.

Aircraft Carrier (CVN) Battle Group.

ο 1 OR, 40-60 beds, 3 ICU beds.

ο 1 surgeon, 5 other medical officers.

ο Up to 9 ships, but usually only the CVN has physicians.

Medical assets aboard aircraft carriers are intended for use

by the aircraft carrier and its task force. Aircraft carriers

are NOT casualty receiving ships and are not figured into

medical assets for support to ground forces.

USMC.

ο Surgical Company.

♦ Provides surgical care for a MEF (Marine Expeditionary

Force). Basis of allocation is 1 per infantry regiment.

♦ 3 ORs, 60-bed capability.

♦ Patient holding time up to 72 hours.

♦ Stabilizing surgical procedures.

ο Forward Resuscitative Surgical System (FRSS).

♦ Embedded organically as part of the TO&E of the

surgical company, if employed reduces the capability

of its parent surgical company.

2.5

Emergency War Surgery

♦ Rapid assembly, highly mobile.

♦ Resuscitative surgery for 18 patients within 48 hours

without resupply.

♦ 1 OR, 2 surgeons.

♦ No holding capability.

♦ No intrinsic evacuation capability.

♦ Chem/bio protected.

♦ Stand alone capable.

Level III

Represents the highest level of medical care available within

the combat zone with the bulk of inpatient beds. Most

deployable hospitals are modular, allowing the commander to

tailor the medical response to expected or actual demand.

Army.

Two different Corps-level Combat Support Hospital (CSH)

designs.

♦ Medical Force 2000 (MF2K) CSH.

♦ Medical Reengineering Initiative (MRI) CSH will

replace the MF2K.

Combat Support Hospital.

♦ MF2K CSH.

◊ Resuscitation, initial surgery, post-op care, and either

return to duty or stabilize for further evacuation.

◊ Up to 296 patients, typically divided into 8 ICUs (96

ICU beds), and 7 Intermediate Care Wards (ICWs)

(140 beds), 1 neuropsychiatric (NP) ward (20 beds),

and 2 minimal care wards (40 beds).

◊

175 officers, 429 enlisted; specialty attachments may

increase numbers.

◊ Up to 8 OR tables for a maximum of 144 operating

hours per day.

◊ General, orthopedic, urologic, neurosurgical, dental

and oromaxillofacial surgery.

◊ Blood bank, laboratory, X-ray/computer tomography

(CT); nutrition, physical therapy and NP capabilities.

◊ Dependent on a number of Corps support elements

for personnel, finance, mortuary, legal, laundry,

2.6

Levels of Medical Care

security, and enemy prisoners of war (EPW)

management, support.

◊

Transportation support required for both incoming

and outgoing patient evacuation, and to transport

the hospital.

◊

Transported via semitrailer, railcar, air cargo, or ship.

◊

Fully deployed CSH (including motor pool, billeting,

heliport, and other life support activities) covers 30.3

acres.

◊

Divided into modules, deployed as a single unit or

separately as the mission dictates. The main modules

are the Hospital Unit-Base (HUB) and the Hospital

Unit-Surgical (HUS).

HUB is the infrastructure of the CSH.

Up to 236 patients, divided into 36 ICU, 140

intermediate, 40 minimal, and 20 NP beds.

Two operating modules with specialty

surgical care capability.

HQ, administrative, personnel, chaplain,

laboratory, pharmacy, X-ray, and blood bank

services.

Part of the HUB can be chem/bio protected

(FM 4-02.7).

HUS capabilities.

60 ICU patients, 2 OR modules, X-ray.

Dependent on the HUB for all logistical

support.

Can be deployed forward, separate from the

HUB, for brief periods as the mission dictates.

MRI CSH (Corps).

ο Provides hospitalization and outpatient services for all

classes of patients in the theater, either returned to duty

or stabilized for further evacuation.

ο Headquarters/headquarters detachment: 15 officers and

44 enlisted.

ο Up to 248 patients, typically divided into an 84-bed

hospital company and a 164-bed hospital company, with

split base operations capability.

2.7

Emergency War Surgery

♦

84-bed hospital company.

◊

24 ICU beds.

◊ Up to 2 OR tables, maximum of 36 operating hours

per day.

◊

3 ICWs (total 60 beds, including NP patients).

◊

56 officers and 112 enlisted personnel.

Some patient care areas can be chem/bio protected.

♦

164-bed hospital company.

◊

24 ICU beds.

◊ Up to 4 OR tables, maximum of 60 operating hours

per day.

◊

7 ICWs (total 140 beds, including NP patients).

◊

84 officers and 169 enlisted personnel.

Some patient care areas can be chem/bio protected.

♦ Applicable to 84-, 164-, and 248-bed (see CSH [Echelon

of Care, EAC] below) hospital companies.

◊ General, orthopedic, urologic, thoracic, OB/GYN,

neurosurgical, dental and oromaxillofacial surgery.

◊ Blood bank, laboratory, X-ray, nutrition, and physical

therapy.

◊ Dependent on EAC support elements for personnel,

finance, mortuary, legal, laundry services, security

and EPW support.

◊ Parts can be chem/bio protected.

◊ Transportation support required for both incoming

and outgoing patient evacuation, and to transport

the hospital.

◊ Transported by semi-trailer, railcar, air cargo, or ship.

◊ Fully deployed, covers 5.7 acres.

◊ Minimal care wards are provided by an attached

minimum care detachment.

Air Force.

ο EMEDS +25.

♦ 25-bed version of EMEDS Basic.

♦ 84 personnel, 2 OR tables, 9 x 600 sq ft tents, and 20

pallets.

♦ 20 operations in 48 hours.

♦ Can be chemically hardened.

2.8

Levels of Medical Care

♦ Additional specialty modules can be added, including

vascular/cardiothoracic, neurosurgery, OB/GYN, ear,

nose and throat (ENT), ophthalmology teams; each

comes with own personnel and equipment.

Navy.

ο Fleet Hospital.

♦ 500-bed hospitals, 80 ICU beds, and 6 ORs.

♦ 1,000 personnel.

♦ Stand alone; full ancillary services.

♦ 8-10 days to be operational.

♦ Large footprint — 28 acres, 450 isolation (ISO) shelters.

♦ No limit on holding capability.

ο Hospital Ships (TAH) — USNS Mercy and USNS Comfort.

♦ 1,000 beds, 100-bed ICU capability, and 12 ORs.

♦ 1,000 staff, over 50 physicians.

♦ Extensive laboratory and X-ray capabilities.

♦ Patient holding is doctrinally limited to 5 days.

Level IV

Definitive medical and surgical care outside the combat zone,

yet within the communication zone/EAC of the theater of

operations (TO).

Patients requiring more intensive rehabilitation or special

needs.

Traditionally includes the MF2K Field Hospital (FH) and

General Hospital (GH).

In some situations, the MF2K CSH or a fixed hospital may

act as a Level IV facility (eg, Landstuhl Army Regional

Medical Center, Germany).

ο Field Hospital.

♦ Semipermanent hospital that provides primarily

convalescent care.

♦ At least 2 OR tables for 24 OR hours per day.

♦ General, orthopedics, OB/GYN, urologic, oral surgery,

and dental services.

♦ Up to 504 patients, with 2 ICUs (24 patients), 7 ICWs

(140 patients), 1 NP ward (20 patients), 2 minimum care

wards (40 patients), and 7 patient support sections (280

patients).

2.9

Emergency War Surgery

ο General Hospital.

♦ Usually a permanent or semipermanent facility.

♦ At least 8 OR tables for 144 OR hours per day.

♦ General, orthopedic, gynecologic, urologic, and oral surgery.

♦ Dental and optometry services.

♦ Outpatient specialty and primary care services.

♦ Up to 476 patients, with 8 ICUs (96 patients), 16 ICWs

(320 patients), 1 NP ward (20 patients), and 2 minimum

care wards (40 patients).

The MRI CSH Echelon Above Corps (EAC) will replace

the FH and GH.

CSH (EAC).

ο Headquarters/headquarters detachment: 17 officers and

33 enlisted.

ο Cannot operate in a split-based mode like the CSH (Corps).

ο 248-bed hospital company.

♦ 4 ICUs (total 48 ICU beds), and 10 ICWs (total 200 beds,

including NP patients). A specialty clinic section that

can treat NP patients. Minimal care wards are provided

by attached minimum care detachments.

♦ 140 officers, 244 enlisted personnel.

♦ Up to 6 OR tables for 96 operating hours per day.

♦ Fully deployed (including motor pool, troop billeting,

heliport, and other life support activities), covers 9.3

acres.

♦ See other general characteristics under MRI CSH

(Corps).

Level V

This level of care is provided in the CONUS. Hospitals in the

CONUS sustaining base will provide the ultimate treatment

capability for patients generated within the theater. Department

of Defense (DoD) hospitals (military hospitals for the tri-

services) and Department of Veterans Affairs (DVA) hospitals

will be specifically designated to provide the soldier with

maximum return to function through a combination of medical,

surgical, rehabilitative, and convalescent care. Under the

2.10

Chapter 3

Triage

Introduction

Modern combat casualty evacuation has become so immediate

and efficient that it can result in a mass casualty situation at

military treatment facilities (MTFs) within the military medical

care system. Consequently, a method of dealing with the

conflicting factors of severity of injury, the tactical situation, the

mission, and the resources available for treatment and

evacuation is essential. Triage is an attempt to impose order

during chaos and make an initially overwhelming situation

manageable.

Triage is the dynamic process of sorting casualties to

identify the priority of treatment and evacuation of the

wounded, given the limitations of the current situation, the

mission, and available resources (time, equipment,

supplies, personnel, and evacuation capabilities).

Triage occurs at every level of care, starting with buddy and

medic care, extending through the OR, the ICU, and the

evacuation system.

The ultimate goals of combat medicine are the return of

the greatest possible number of soldiers to combat and the

preservation of life, limb, and eyesight in those who must

be evacuated.

The decision to withhold care from a wounded soldier who in

another less overwhelming situation might be salvaged, is

difficult for any surgeon or medic. Decisions of this nature are

infrequent, even in mass casualty situations. Nonetheless, this

is the essence of military triage.

3.1

Emergency War Surgery

Triage Categories

It is anticipated that triage will be performed at many levels,

ranging from the battlefield to the battalion aid station to the

field hospital. Traditional categories of triage are Immediate,

Delayed, Minimal, and Expectant. This classification scheme

is useful for mass casualties involving both surgical and medical

patients. An additional category of Urgent has been used to

describe surgical patients who need an operation but can wait a

few hours.

Immediate: This group includes those soldiers requiring life-

saving surgery. The surgical procedures in this category

should not be time consuming and should concern only those

patients with high chances of survival (eg, respiratory

obstruction, unstable casualties with chest or abdominal

injuries, or emergency amputation).

Delayed: This group includes those wounded who are badly

in need of time-consuming surgery, but whose general

condition permits delay in surgical treatment without unduly

endangering life. Sustaining treatment will be required (eg,

stabilizing IV fluids, splinting, administration of antibiotics,

catheterization, gastric decompression, and relief of pain).

The types of injuries include large muscle wounds, fractures

of major bones, intra-abdominal and/or thoracic wounds,

and burns less than 50% of total body surface area (TBSA).

Minimal: These casualties have relatively minor injuries (eg,

minor lacerations, abrasions, fractures of small bones, and

minor burns) and can effectively care for themselves or can

be helped by nonmedical personnel.

Expectant: Casualties in this category have wounds that are

so extensive that even if they were the sole casualty and had

the benefit of optimal medical resource application, their

survival would be unlikely. The expectant casualty should

not be abandoned, but should be separated from the view of

other casualties. Expectant casualties are unresponsive

patients with penetrating head wounds, high spinal cord

injuries, mutilating explosive wounds involving multiple

anatomical sites and organs, second and third degree burns

in excess of 60% TBSA, profound shock with multiple injuries,

and agonal respiration. Using a minimal but competent staff,

provide comfort measures for these casualties.

3.2

Triage

Alternative Triage Categories

In practice, however, the division of patients into these four

categories is not useful for a surgical unit. The casualties should

be divided into emergent, nonemergent, and expectant. These

divisions are useful in dividing casualties into those requiring

further surgical triage (emergent), and those that are less injured,

still require care, but have little chance of dying (nonemergent).

It is anticipated that 10%-20% of casualties presenting to a

surgical unit will be in the emergent category, requiring urgent

surgery. The vast majority of wounded will not require intensive

decision-making, intervention, and care.

Emergent: Although this category has been historically

subdivided into Immediate (unstable and requiring attention

within 15 minutes) and Urgent (temporarily stable but

requiring care within a few hours), except in the most

overwhelming circumstances, such division is rarely of

practical significance. This group of wounded will require

attention within minutes to several hours of arriving at the

point of care to avoid death or major disability.

ο Types of wounds include:

♦ Airway obstruction/compromise (actual or potential).

♦ Uncontrolled bleeding.

♦ Shock.

◊ Systolic BP < 90 mm Hg.

◊ Decreased mental status without head injury.

♦ Unstable penetrating or blunt injuries of the trunk,

neck, head, and pelvis.

♦ Threatened loss of limb or eyesight.

♦ Multiple long-bone fractures.

Nonemergent: This category was historically divided between

Delayed (would require intervention, however, could stand

significant delay) and Minimal. This is the group of patients

that, although injured and may require surgery, does not require

the attention of the emergent group and lacks significant

potential for loss of life, limb, or eyesight. Examples include:

ο Walking wounded.

ο Single long-bone fractures.

ο Closed fractures.

ο Soft tissue injuries without significant bleeding.

ο Facial fractures without airway compromise.

3.3

Emergency War Surgery

Expectant: This group of wounded, given the situation and

resource constraints, would be considered unsalvageable.

Examples may include:

ο Any casualty arriving without vital signs or signs of life,

regardless of mechanism of injury.

ο Transcranial gunshot wound (GSW).

ο Open pelvic injuries with uncontrolled bleeding; in shock,

with decreased mental status.

ο Massive burns.

Special categories: Patients who do not easily fit into the

above categories and casualties who pose a risk to other

casualties, the medics, and the treatment facility, may require

special consideration:

ο Wounded contaminated in a biological and/or a chemical

battlefield environment. The threat posed by these

patients mandates decontamination prior to entering the

treatment facility. Appropriately protected medical

personnel may treat emergent casualties prior to

decontamination.

ο Retained, unexploded ordnance: These patients should

be segregated immediately. See Chapter 1, Weapons Effects

and Parachute Injuries, which describes the special

handling of these wounded.

ο Enemy Prisoners of War (EPWs)/Internees: Although

treated the same as friendly casualties, it is essential that

the threat of “suicide bombers” and “human booby traps”

be prevented by carefully screening all EPWs prior to

moving into patient areas, including the triage area. See

Chapter 34, Care of Enemy Prisoners of War/Internees.

Combat stress: Rapid identification and immediate

segregation of stress casualties from injured patients will

improve the odds of a rapid recovery. With expeditious care

these casualties can be returned to duty (80%). Do not use

them as litter bearers as this may increase the trauma you

seek to treat.

ο Place patient in one of two groups.

♦ Light stress: Immediate return to duty or return to unit

or unit’s noncombat support element with duty

limitations and rest.

3.4

Triage

♦ Heavy stress: Send to combat stress control restoration

center for up to 3 days reconstitution.

♦ Use BICEPS mnemonic where resources/tactical

situations allow.

◊

Brief: Keep interventions to 3 days or less of rest,

food, reconditioning.

◊

Immediate: Treat as soon as symptoms are

recognized—do not delay.

◊

Central: Keep in one area for mutual support and

identity as soldiers.

◊

Expectant: Reaffirm that we expect return to duty

after brief rest; normalize the reaction and their duty

to return to their unit.

◊

Proximal: Keep them as close as possible to their unit.

This includes physical proximity and using the ties

of loyalty to fellow unit members. Do this through

any means available. Do not evacuate away from

the area of operations or the unit, if possible.

◊

Simple: Do not engage in psychotherapy. Address

the present stress response and situation only, using

rest, limited catharsis, and brief support (physical

and psychological).

◊

Or, refer: Must be referred to a facility that is better

equipped or staffed for care.

If battlefield casualties do not have physical injuries, DO

NOT send them out of the battle area, as this will worsen

stress reactions, and possibly start evacuation syndromes!

Triage is a fluid process at all levels, with altered situations

and resources requiring a change in category at any time

and in any setting. In the extreme example, a casualty may

be triaged from emergent to expectant during surgery,

abruptly terminating the procedure (“on-the-table triage”).

Resource Constraints

Including all of the factors that influence triage decision

making would be encyclopedic and of little benefit. Rather, a

3.5

Emergency War Surgery

framework for thinking about this process in a logical fashion

is presented here.

External factors. The surgeon/medic may have limited

knowledge of and no control over external issues.

Nonetheless, optimal casualty care requires at least an

assessment of these factors.

Tactical situation and the mission. The decision to commit

scarce resources cannot be based on the current tactical/

medical/logistical situation alone. One severely wounded,

resource-consuming casualty may deplete available

supplies, and thus prevent future, less seriously injured

casualties from receiving optimal care. Liaison with the

tactical force operating in your area is essential to making

sound triage decisions. Operational security may make this

kind of information difficult to obtain in a timely fashion.

Education of, and communication with, line commanders

about the critical nature of this information is essential.

Resupply: Having a sense of how and when expended

internal resources will be resupplied may prove critical to

making the decision to treat or not treat the individual

casualty.

Time.

♦ Evacuation to the MTF. The shorter this time interval,

expect the complexity of triage decisions to increase,

especially sorting the worst emergent patients from the

expectant. Longer intervals will result in the opposite, with

“autotriage” of the sicker patients from the emergent to

the expectant/dead on the battlefield category.

♦ Time spent with the individual casualty. In a mass

casualty situation, time itself is a resource that must be

carefully triaged/husbanded. All patients receive an

evaluation, but only some receive operative

intervention. Time on the OR table is usually the choke

point. Apply the concepts of damage control to

minimize the time casualties spend in surgery. On-table

triage to expectant may be necessary due to

deteriorating casualty physiologic response and/or the

pattern of injury

(aorta-vena cava GSW, dual

3.6

Triage

exsanguination sites, extensive pancreatic-duodenal

injury, and so forth).

♦ Evacuation out. Casualties must move expeditiously

to the next echelon of care (EOC), otherwise valuable

local resources will be consumed in maintaining

patients, thereby preventing additional patients from

receiving care.

Internal factors. These issues are known to the surgeon/

nurse/medic and should be factored into triage decisions.

Medical supplies. These supplies include equipment,

drugs, oxygen, dressings, sutures, sterilization capability,

blood, etc. Immediate liaison with the logistics system in

the MTF and the theater of operation is essential to ensure

the availability and timely resupply of these items, to

include “surge” capabilities and local resource availability.

Space/Capability. This category includes the number of

OR tables and ICU beds: the holding capacity and ward

capacity; and the available diagnostic equipment—

ultrasound (US), X-ray, computed tomography (CT)—and

laboratory tests. For example, if your MTF has the only

CT scanner in theater, plan for an increased number of

head-injured patients.

Personnel. This includes knowing the professional

capability (type and experience of individual physician/

nurse/medic), and the emotional stability, sleep status, and

so forth, of your hospital personnel. This perishable

resource must be preserved; for example, 24 hours of

continuous operation may exhaust your only OR crew, and

may necessitate diversion of casualties to another facility.

Stress. Soldiers, including medical personnel, are

affected by the consequences of war; individual and unit

capability is degraded during sustained operations. The

personal impact of military triage on the medical team

cannot be overemphasized. It is extremely emotional,

and measures should be undertaken to minimize these

effects. This is best provided by trained staff. Cohesive

groups may tolerate stress better and assist each other

in dealing with traumatic events when allowed to

3.7

Emergency War Surgery

process the event in a group format according to their

own traditions.

Triage Decision Making

The complexity of decision making in triage varies greatly, often

depending on the level of training and experience of the triage

officer, as well as the location where the triage decision is being

made. At the front line, the medic must make a decision about

whether or not to evacuate patients from the battlefield and how

fast. The following decision tree is an example of a triage tool

that may be used in the field as an initial decision-making aid.

Walking

NONEMERGENT

Responsive to shake and shout

YES

Palpable radial pulse and

Breathing with airway open

comfortable breathing

or with simple maneuver

YES

NONEMERGENT

EMERGENT

EXPECTANT/DEAD

In the emergent treatment area, the surgeon must make decisions

about whether surgery is needed, the timing of the surgery, and

the priority of multiple surgical patients. Regardless of the type

of triage decision needed, the following information is of critical

importance in reaching that decision:

Initial vital signs. Pulse (rate and quality), mentation,

difficulty breathing (eg, a casualty with normal mentation

3.8

Triage

and radial pulse quality is nonemergent). Respiratory rate

alone is not predictive of the appropriate triage category.

Pattern of injury. A historical perspective aids the triage

decision maker in understanding the distribution of wounds

encountered on the modern battlefield and the likely

mortality associated with those wounds. The majority of

combat wounded will suffer nonfatal extremity injuries.

In general, these will be triaged as nonemergent.

Response to initial intervention. Does the shock state

improve, remain unchanged, or worsen with initial

resuscitative efforts? A patient who fails to respond rapidly

to initial fluid resuscitation should be triaged ahead of a

patient with a good response to minimal fluid replacement;

alternatively, this nonresponder in a mass casualty situation

may need to be placed in the expectant category.

The following data from the Vietnam War indicate the numerical

distribution of diagnoses that were seen in the low-intensity

light-infantry combat that characterized that war. Casualties from

armored combat can be expected to have a higher prevalence of

burns and multiple injuries. Of 100 injured in combat:

30%—Minor or superficial wounds (minor burns,

abrasions, intraocular foreign body, ruptured tympanic

membrane/deafness).

16%—Open comminuted fractures of a long bone. Several

patients with multiple fractures and injuries to named

nerves and blood vessels.

10%—Major soft tissue injury or burn requiring

general anesthesia for treatment. Several had an injury

to major nerves.

10%—Had laparotomies, two of which were negative, and

several involved extensive, complicated procedures.

6%—Open comminuted fractures of hand, fingers, and feet.

5%—Required closed thoracostomy and had soft tissue

wounds.

4%—Major multiple trauma.

3%—Major amputations (above the knee [AK], below the

knee [BK], below the elbow [BE], above the elbow [AE]).

In three out of four cases, the surgical procedure simply

required completion of the amputation.

3.9

Emergency War Surgery

ο 3%—Craniotomies. Two were for fragments and one for

a depressed skull fracture.

ο 3%—Vascular repair (one was to repair a femoral artery, and

another involved named nerves or fractures).

ο 3%—Major eye injuries, one involving enucleation.

ο 2%—Minor amputations (toes, fingers, hand, foot).

ο 2%—Maxillofacial reconstructions (one half were

mandibular injuries, and most of the rest were maxillary).

ο 1%—Formal thoracotomy.

ο 1%—Neck exploration.

ο 1%—“Miscellaneous.”

Data from more recent American combat operations in Iraq (OIF)

and Afghanistan (OEF), 2003-2004, indicating the spectrum of

injury type (Table 3-1), mechanism (Table 3-2), and anatomical

location (Table 3-3) are found below.

Table 3-1. Type of Injury.*

Type of Injury

Frequency

Percent

Penetrating

645

35.7%

Blast

425

23.5%

Blunt

410

22.7%

Unknown

4.6%

Crush

3.5%

Mechanical

2.7%

Thermal

2.7%

Undetermined

1.2%

Other

0.9%

Chemical agent

0.6%

Bites/Stings

0.4%

Degloving

0.4%

Electrical

0.4%

Heat Injury

0.4%

Inhalation

0.2%

Multiple Penetration System

0.2%

Total

1807

100%

A casualty may have more than one type of injury. These numbers are based

on 1530 Level III casualties.

3.10

Triage

Table 3-2. Mechanism of Injury.*

Mechanism of Injury

Frequency

Percent

IED

310

18.4%

MVA

207

12.3%

Gun Shot Wound (GSW)

188

11.1%

Grenade (includes RPG)

170

10.1%

Shrapnel/Fragment

141

8.3%

Unknown

119

7.0%

Machinery or Equipment

5.6%

Fall or Jump from height

5.3%

Mortar

5.0%

Burn

3.1%

Aggravated Range of Motion

1.8%

Landmine

1.7%

Other

1.6%

Knife or other sharp object

1.2%

Helicopter Crash

1.1%

Blunt object (eg, rock or bottle)

1.0%

Pedestrian

0.9%

Free Falling Objects

0.8%

Bomb

0.7%

None

0.7%

UXO

0.6%

Environmental

0.5%

Exertion/overexertion

0.3%

Flying debris

0.3%

Building Collapse

0.1%

Hot Object/Substance

0.1%

Altercation, fight

0.1%

Total

1689

100%

A casualty may have more than one mechanism of injury. These numbers are

based on 1530 Level III casualties.

Setup, Staffing, and Operation of Triage System

Initial Triage Area.

All casualties should flow through a single triage area and

undergo rapid evaluation by the initial triage officer.

Casualties will then be directed to separate treatment areas

(emergent, nonemergent, and expectant), each with its own

triage/team leader. The expectant will have a medical

attendant, ensuring optimal pain control. The dead should

3.11

Emergency War Surgery

Table 3-3. Anatomical Location of Injury.*

Anatomical Location

Frequency

Percent

Multiple Sites

761

49.7%

Lower Extremity

248

16.2%

Upper Extremity

223

14.6%

Head/Face

174

11.4%

Thorax/Back

3.1%

Neck

1.3%

None

1.3%

Abdomen

1.0%

Unknown

0.6%

Buttock

0.4%

N/A

0.2%

Genitalia

0.1%

Soft Tissue

0.1%

Total

1530

100%

Casualties with more than one injury location are included in ‘Multiple Sites’.

These numbers are based on 1530 Level III casualties.

be sent to the morgue and must remain separate from all other

casualties, especially the expectant. Unidirectional flow of

patients is important to prevent clogging the system. Reverse

patient flow in any treatment area is highly discouraged.

No significant treatment should occur in the triage area.

Casualties should be rapidly sent to the appropriate

treatment area for care.

ο Qualities of an ideal initial triage area should include

♦ Proximity to the receiving area for casualties—LZ,

ground evacuation, decontamination area.

♦ One-way flow both into and out of the triage area

through separate routes to easily identified, marked

(signs, colors, chemical lights, etc.) treatment areas.

♦ Well-lit, covered, climate-controlled (if possible) area

with sufficient space for easy access, evaluation, and

transport of casualties in and out.

♦ Dedicated casualty recorders to identify, tag, and record

initial triage/disposition.

3.12

Triage

◊ Using an indelible marker to place numbers on the

casualty’s forehead is an easy, fast way to track patients.

Any method that is reproducible and simple will suffice.

◊ If resources allow, casualty tracking may include

stationing administrative personnel at every entry/exit.

♦ Sufficient litter bearers (controlled by an NCO) to

ensure continuous casualty flow.

ο Initial triage office.

♦ Ideally, a surgeon experienced in dealing with combat

trauma should be used in this capacity. Unfortunately,

using a surgeon outside of the OR is a luxury that most

small forward surgical units cannot afford.

♦ It is essential that another person with clinical

experience be trained to assume this function. Using

mass casualty exercises or limited mass casualty

situations is one way to train/identify the right person

to fill this role in the absence of a surgeon.

Emergent treatment area.

Setup.

♦ Close proximity to initial triage area with direct access.

♦ Administrative personnel stationed at entry and exit

doors to record patient flow. Ideally, a display board or

a computer should be used to record patient identity,

location, and disposition.

♦ Series of resuscitation bays (number depends on

available resources/personnel).

◊ Allow sufficient room for 3-person team to work.

◊ Easy access in and out of bay.

◊ Availability of equipment needed for ATLS style

resuscitation (Fig. 3-1 a,b).

Staffing.

♦ Team leader: a surgeon serves as the surgical triage officer.

◊ Responsible for determining priority for operative

interventions.

◊ Needs to identify patients that require early evacuation.

◊ If a surgeon is unavailable, may be a physician who main-

tains close communication with the operating surgeons.

♦ Administrative person. Responsible for recording flow

of patients through unit.

3.13

Emergency War Surgery

♦ Team Leader retriages patient and assigns resuscitation

team to patient.

♦ Resuscitation team treats patient and determines required

disposition (surgery, ICU, ward, air evacuation).

♦ Resuscitation team communicates to Team Leader the

recommended disposition.

♦ Team Leader coordinates movement of patient to next stop.

♦ Administrative person records disposition.

Nonemergent treatment area.

An empty ward, a cleared out supply area, or other similar

space can be utilized. Appropriate medical and surgical

supplies should be stockpiled and easily identifiable. A

team consisting of a physician and several nurses and

medical technicians can form the nucleus of the treatment

team. Lacerations can be sutured, closed fractures splinted,

IVs placed, and radiographs taken. The team leader should

be alert to changing vital signs, mental status changes, and

any failure to respond to appropriate treatment measures.

Any evidence of deterioration should prompt a retriage

decision and a possible transfer to the emergent treatment

area.

Expectant area.

Ideally, expectant casualties should be kept in an area away

from all other treatment areas. The team leader can be anyone

capable of giving parenteral pain medications. The patient

should be kept comfortable. After all other patients have

been treated, a retriage of these patients should be done

and treatment instituted if appropriate.

Additional Triage Operation Tips

Diversion of casualties to another facility should be

considered. These options (sister service, local national

assistance, or local NATO assets) should be established prior

to the mass casualty event.

As the casualties finally clear the OR suites, the pace will

slow for the surgeons. ICU and ward care will supplant

operative procedures. Casualties initially undertriaged

(~10%) will be discovered and will require care. The

recovery room and ICUs will become crowded, nursing

3.16

Triage

shifts will have to be extended, and fatigue will rapidly

become a hospital-wide factor.

Numerous authors have stated that after the first 24 hours

of a mass casualty ordeal, the activities of the care

providers must be decreased by 50%, allowing for recovery

and rest for the participants, and a new rotation must be

established to sustain a modified but continuous effort.

Once the press is over, personnel must be encouraged to

rest rather than to socialize. Rest must be enforced because

the entire scenario may recur at any time.

Prior to an actual mass casualty situation, all deployable

units should exercise a variety of triage scenarios to ensure

smooth patient flow and identification. ”Driving” litters

without running into things can be difficult unless

practiced! These scenarios should evaluate personnel,

supplies, and equipment.

Conclusion

Small, highly mobile units, either Special Operations or

conventional forces, are currently performing military

operations around the globe. These units are usually

supported by highly mobile, small footprint surgical elements

that have limited diagnostic, operative, holding, and resupply

capability. Evacuation may entail an extremely long transport

from point of wounding to the forward surgery team, then

another long transport directly to a Level IV/V. Air

superiority may be in question, especially the use of

helicopters for initial patient evacuation. In these situations

the tactical, logistic, and physiologic integration of triage

concepts becomes of paramount importance and needs to be

considered and extensively discussed prior to arrival of the

first casualty.

3.17

Chapter 4

Aeromedical Evacuation

Introduction

Evacuation of injured personnel using aircraft, fixed or rotary

wing, has revolutionized the rapid transport of casualties from

areas where there is either inadequate or no care available to

medical treatment facilities (MTFs) where essential and/or

definitive care can be rendered. While an aircraft can decrease

transport time, the aeromedical environment creates unique

stresses on the injured patient. The following are terms that

describe evacuation of patients using aircraft.

Casualty evacuation (CASEVAC): The movement of a

casualty from the point of injury to medical treatment by

nonmedical personnel. Casualties transported under these

circumstances do not receive en route medical care; if the

casualty’s medical condition deteriorates during transport,

an adverse impact on the casualty’s prognosis and long-term

disability may result. Traditionally, this situation involves a

helicopter mission returning from the battlefield.

Medical evacuation (MEDEVAC): The timely, efficient

movement and en route care provided by medical personnel

to the wounded being evacuated from the battlefield to MTFs,

using medically equipped vehicles or aircraft. Examples

include civilian aeromedical helicopter services and Army

air ambulances. This term also covers the transfer of patients

from the battlefield to an MTF or from one MTF to another

by medical personnel, such as from a ship to shore.

Aeromedical evacuation (AE): Providing USAF fixed-wing

intratheater (Tactical Evacuation [TACEVAC]: from the

combat zone to points outside the combat zone, and between

points within the communications zone) and intertheater

(Strategic Evacuation [STRATEVAC]: from out of the theater

4.1

Emergency War Surgery

of operations to a main support area) movement of sick or

injured personnel, with enroute care provided by AE

crewmembers and critical care air transport teams (CCATTs),

to locations offering appropriate levels of medical care.

Enroute care: Maintenance of treatment initiated prior to

evacuation and sustainment of the patient’s medical condition

during evacuation.

Medical Considerations for Patients Entering the Medical

Evacuation System

Medical Considerations/Requirements

Medical evacuation request includes requirement for

surgical equipment and/or providers.

Patient is sufficiently stabilized for the anticipated mode

and duration of travel.

Patient’s airway and breathing is adequate for

movement.

Patient’s IV lines, drainage devices, and tubes are fully

secured and patent.

Patient at high risk for barotrauma should be considered

for prophylactic chest tube placement before prolonged

aeromedical evacuation.

Heimlich valves on chest tubes are functioning.

Foley catheters and nasogastric (NG) tubes are placed

and allowed to drain.

Patient is securely covered with both a woolen and

aluminized blanket for air transport, cold environment,

or postoperative hypothermia.

3 litter straps are used to secure the patient to the litter.

Personal effects and all medical records accompany the

patient.

The evacuation of a patient is initiated by the surgeon

according to established procedures. The support patient admin-

istration personnel normally provide the administrative

details and coordination required to accomplish the

evacuation. Due to differences in the type of evacuation assets

used and their effect on the patient’s medical condition (such

4.2

Aeromedical Evacuation

as flying in the pressurized cabin of an aircraft), patients

entering the USAF AE system must also be validated for

evacuation by the supporting flight surgeon.

For patients evacuated from Level II MTFs or forward surgical

teams (FST), the brigade surgeon (or designee) determines the

evacuation precedence for all patients requiring evacuation

from that facility. This is done in consultation with the

forward surgical team’s chief surgeon and/or senior nurse.

When a patient is readied for evacuation from the forward

surgical team by USAF assets, the supporting patient move-

ment requirements center (PMRC) should be established at

the earliest possible time. This allows the PMRC sufficient

time to coordinate airlift and patient movement items

requirements.

Implications of Aviation Environment

General Considerations Prior to Transport.

Due to altitude effects, limited mobility, decreased staffing

enroute, and unpredictable evacuation times, the referring

physician should tailor vital signs (VS) monitoring

requirements, and frequency of wound and neurovascular

checks.

Some therapies that might not be used in a fixed MTF are

appropriate for AE.

♦ For example, patients with significant medical or

surgical conditions should have Foley catheters, NG

tubes, provisions for IV pain medications, extended

duration IV antibiotics.

Consider liberal use of fasciotomies/escharotomies.

Consider securing airway with prophylactic endotracheal

(ETT) tube.

Wounds dressed for delayed primary closure. Unless

directed otherwise, AE crew should not routinely re-dress

wounds. If a patient develops fever or sepsis enroute,

wounds must be inspected.

Casts must be bivalved. If the cast is over a surgical wound

site, “window” the cast to allow for tissue expansion and

emergency access. Document neurovascular checks prior

to and frequently during flight.

4.3

Emergency War Surgery

Decreased Barometric Pressure.

ο The diameter of a gas bubble in liquid doubles at 5,000 ft

above sea level, doubles again at 8,000 ft, and doubles again

at 18,000 ft. Cabin pressures in most military aircraft are

maintained at altitudes between 8,000 and 10,000 feet. If

an aircraft has the capability, the cabin altitude can be

maintained at lower levels, with increased flight time and

fuel.

Consider a Cabin Altitude Restriction (CAR) for the

following:

ο Penetrating eye injuries with intraocular air.

ο Free air in any body cavity.

ο Severe pulmonary disease.

ο Decompression sickness and arterial gas embolism require

CAR at origination field altitude. Destination altitude

should not be higher than origination altitude. Transport

on 100% oxygen (by aviator’s mask if available).

Pneumothorax: Chest tube required, even for small,

asymptomatic lesions. A Heimlich valve or collection system

must be in place prior to patient transfer to the flight line.

Air Splints: Should not be used if alternate devices are

available. Because air expands at altitude, air splints require

close observation and adjustments during flight.

Ostomy Patients: Vent collection bags to avoid excess gas

dislodging the bag from the stoma wafer. Use a straight pin

to put two holes in the bag above the wafer ring.

Decreased Partial Pressure of Oxygen: Ambient partial

pressure of oxygen decreases with increasing altitude. At sea

level, a healthy person has an oxygen saturation of 98%-100 %.

At a cabin altitude of 8,000 ft, this drops to 90%, which corrects

to 98%-100% with 2 L/min of oxygen.

Neurosurgical Patients: Hypoxia may worsen neurological

injury. Adjust ventilator settings to meet increased oxygen

demands at altitude.

Gravitational Stress: Traumatic brain injury patients can

experience transient marked increases in intracranial pressure

during takeoff or landing. Patient positioning onboard the

aircraft helps minimize this risk (head forward on takeoff,

head rearward on landing).

4.4

Aeromedical Evacuation

Thermal Stress: Plan for cabin temperature changes from 15°C

(59°F) to 25°C (77°F) on winter missions, and from 20°C (68°F)

to 35°C (95°F) on summer missions.

Noise: Exposure to noise can produce problems with

communication and patient evaluation (auscultation is

impossible — use noninvasive blood pressure [NIBP] and

an arterial line). Provide hearing protection. Audible medical

equipment alarms are useless.

ο Decreased Humidity: Airplanes have very low cabin

humidity at altitude. Evaporative losses will increase;

therefore, patients will require additional fluids, especially

those with large burns, and those at risk for mucous

plugging.

Patient movement in nuclear, biological and chemical (NBC)

environments.

ο Nuclear and chemical casualties must be externally

decontaminated, and time allowed for off-gassing of

residual chemical agent.

ο Movement of biological casualties varies by the nature of

the agent, its mechanism of transmission, and the period

of communicability during the course of illness.

ο Any NBC AE movement may be delayed due to the

following:

♦ Aircraft decontamination time.

♦ Availability of noncontaminated aircrew.

♦ Cohorting of similarly exposed patients.

♦ Quarantinable diseases (eg, plague and smallpox)

require special approval (command and diplomatic)

before AE.

Medical Evacuation Precedences

Depending on the Service and the type of evacuation assets

used, the timeframes for affecting evacuation differ. Refer to

Table 4-1.

4.5

Emergency War Surgery

Table 4-1. Evacuation Precedences.

Army, Navy,

Movement

Marine

Precedence

(MEDEVAC) Air Force (AE) Description

Urgent

Within 2 h.

ASAP

Immediate AE to save life,

limb, or eyesight.

Priority

Within 4 h.

Within 24 h.

Prompt medical care not

available locally.

Medical condition could

deteriorate and patient

cannot wait for routine

AE.

Routine

Within 24 h.

Within 72 h or

Condition is not expected

next available

to deteriorate significantly

mission.

while awaiting flight.

Concept of Operations. The USAF AE system.

ο Command and control (C2) of casualty movement by air

transport.

ο AE personnel and equipment for inflight supportive

patient care and flight line support operations.

ο Organic communication network for medical facilities and

airlift C2 agencies.

♦ Aeromedical Evacuation Liaison Team (AELT): 4-6

person communication team, usually collocated with

an MTF, to coordinate requests with the AE system.

ο Facilities and personnel at airheads for the administrative

processing, staging, and limited medical care of casualties

entering or transiting the AE system. Patients are normally

held only for 2-6 hours prior to evacuation.

♦ USAF units provide aeromedical staging support

through incrementally sized elements ranging in size/

capability from forward deployed special operations

forces (SOF) to 100-bed facilities.

Reporting a Patient for AE. Originating physician consults

with local FS to determine the en route care plan and timing

of evacuation.

4.6

Emergency War Surgery (2004) - page 2