Report: Dr. Andreas Otto, LCDR(MC), Military Hospital Westerstede, Dep. Anesthesiology and Intensive Care
German Emergency Physicians on U.S. UH-60 “Black Hawk” MedEvac
From the 30th contingent DEU-ISAF MTF Role 2 Kunduz (Chief of company LtCol(MC) Houda) of the DEU-ISAF MTF (Commander Col(MC) Dr. Höpner)
Since September 2012 a pilot project with DEU Emergency Physicians (DEU EP) on U.S. ForwardAirMedevac-Helicopter continues. The benefit is, in addition to optimize patient treatment, getting experiences for the implementation of the DEU ForwardAirMedEvac-System. The author was deployed from November 2012 till March 2013 to Kunduz being part of this project.
The U.S. Unit in Kunduz
From April 2012 till March 2013 the 12th Combat Aviation Brigade was deployed to Afghanistan for Operation Enduring Freedom (OEF). Stationed in Katterbach and Ansbach (Germany), the 12th Combat Aviation Brigade is part of the Army V Corps in Europe, Wiesbaden. The units had already been deployed to missions in Vietnam, Kuwait, Bosnia, Kosovo and Iraq. Living up to their motto “Wings of Victory“, over 3100 soldiers and 100 “Black Hawk“ und “Chinook“ helicopters are stationed in Germany. About 20 soldiers of the 5./158th Aviation Regiment “Bavarian Dustoff“ were deployed to Kunduz (KDZ) as part of TF Pirate.
The Sikorsky UH-60 “Black Hawk“ is a medium sized transport helicopter built by Sikorsky Aircraft Corporation in the US since 1978 in several versions. Even though initially the latest version with stealth-technology might have been used for the mission to capture Usama-bin-Laden, in KDZ much older versions were flown (built between 1982 and 1984). The UH-60 was introduced to replace the Bell UH-1. In comparison to the Bell, the “Black Hawk“ is equipped with a self-protection system, allows a higher payload and has got a longer range. The “Black Hawk” shows a high power of resistance – even when receiving moderate fire with 23 mm ammunition or loosing main gearbox oil pressure continuing the flight is possible. Due to its lower weight the older version UH-60 is faster than the HH-60 (about 270 km/h) and has a higher range (550km or 130min). However, the UH-60 is less comfortable than the HH-60 version. In KDZ the unit flew with two identically equipped UH-60 MedEvac-Helicopters (lead and chase). Armored protection (e.g. Apache) was rarely needed.
In contrast to German directives (DIN-Norm), the medical equipment on U.S. Army MedEvac-Helicopters is not standardized. Every company equips their helicopters to need in arrangement between pilots and flight surgeon. Also the Medic’s bags are packed individually, depending on individual skill levels. As a result, the medical equipment is quite comparable, usually including a Propaq-patient monitor, a Zoll-M-defibrillator, an Impact 754 Eagle ventilator and an Eagle electronic suction device, further, tourniquets, bandages and devices for airway management or iv-/io-lines as well as three two-liter-bottles of oxygen. Two of the three helicopters in KDZ also were equipped with a hoist for the rescue of patients in rough terrain.
Launching a mission
In the case of soldiers outside the camp KDZ getting ill, injured, or wounded, the platoon leader has to dispatch a 9-line medevac request to the Tactical Operations Center (TOC) in KDZ.
TOC informs the Patient Evacuation Coordination Cell (PECC) in Masar-e-Sharif (MES), PECC decides on the next suitable MedEvac. If this is the U.S. ForwardAirMedEvac UH-60 in KDZ PECC will inform the U.S. TOC in KDZ, where soldiers are on duty 24/7. After taking the call, they alarm the helicopter crews on duty, coordinate “wheels up” in cooperation with the DEU liaison officer responsible for the air traffic (HeliOps) and inform the appropriate Medical Treatment Facility (MTF). Depending on the priority of the patient(s) the ForwardAirMedEvac have a 15 minutes’ Notice-to-Move (NTM) (e. g. Cat. A). Claim of the U.S. comrades is a maximum of 10 minutes; however, usually it takes only seven or eight minutes until the ForwardAirMedEvac is combat ready in the air – day and night.
To keep to this directive, daily “run ups” during shift changeover are necessary. This includes engine starts and all necessary technical check-ups by the crew in order to be ready for mission fast and safe.
The UH-60 “Black Hawk” has a crew of four: pilot, co-pilot, crew chief and the flight medic..
After the Advanced Individual Training, the medics are Health Care Specialists, also called Combat Medics. This provider level is comparable to a civil U.S. Emergency Medical Technician (EMT-B). After Advanced Individual Training, Combat Medics may further specialize to become Laboratory Assistants, Practical Nurses or even Flight Medics. In order to reach the qualification of a Flight Medic, Combat Medics need at least one year of experience and have to be airworthy. In principle, after qualification, Flight Medics are competent to carry out basic emergency treatment focused on traumatic aspects in military settings on their own. After additional training, the supervising Flight Surgeon can issue individual licenses to carry out additional treatment like thorax punction, intubation or application of gastric tubes. The complete system is modular and gives very capable medics the chance to become a Physician Assistant.
The pilot project
Right now, the U.S. Combat Medic Training is going to be restructured. Due to an obvious increase in the complexity of injuries, a higher qualification of Combat Medics up to a level comparable to U.S. civil paramedics is aimed for. The U.S. Army MedEvac-System has its roots in the Vietnam War. Then and during the following wars, injuries were mostly caused by small arms fire. Studies of the wars in Iraq and Afghanistan show a shift towards complex thermo-mechanic combined injuries caused by Improvised Explosives Devices (IED). Until this point, the only aim of the MedEvac missions was to pick up patients from the Point of Injury (POI) and transport them to the next MTF as fast as possible. Deciding factor was time – for an “Alpha” Patient the “golden hour of trauma” had to be kept. This tactic usually allowed the Flight Medic only a short period of time to care for the patient until arriving at the next MTF with more qualified personnel, resulting in the need of high numbers of helicopters and of MTFs if the “golden hour of trauma” was to be kept for every single mission. The increased complexity of injuries by IED (e. g. urological or neurosurgical injuries) might require to fly to the closest suitable MTF, not the nearest even if this means overflying a role 2 facility. This will often result in an increase of flight time and require additional emergency treatment on board (e. g. blood substitution, airway management, initiation of and maintaining anesthesia, treatment with catecholamine). To solve this problem, the U.S. Army is considering concepts of Coalition Forces: The UK MERT-System (Medical Emergency Response Team) in RC South-West of Afghanistan or the Israeli Defence Board set examples – both ideas focus on the deployment of special trained Physicians or Physician Assistants for ForwardAirMedEvac missions.
In October 2011 the first German Emergency Physicians (DEU EP) were deployed and appointed to U.S. MedEvac-Helicopters. One reason was the requirement for highly mobile DEU EP to reach patients as fast as possible. This was found necessary because of an increasing number of small ground force (and mentoring) missions and a decreasing number of Mobile Emergency Physician Teams (MEPT = BAT) on the ground. Another reason was to gain experience for the implementation and organization of the future DEU ForwardAirMedEvac-System. After a brake of a few months the project has been continued since September 2012 with the deployment of two DEU EPs to MES and two more to KDZ.
For this project, the DEU EPs have to possess certain qualifications like being an Emergency Physician and a Pre-Hospital Trauma Life Support (PHTLS)-Provider. The author himself is member of the “Einsatzpool” (“BAT-Pool”), having worked two and a half years in the military hospital in Westerstede, Department of Anesthesiology and Intensive Care. He is also an Emergency Physician and has got a current NATO Language Proficiency (SLP Eng 3332). His participation in the 30th contingent DEU-ISAF was his second deployment after KFOR in 2011.
Although deployed to the DEU ISAF MTF Role 2 KDZ of the DEU ISAF Medical-TF, the DEU EP are living and working together with their fellow Americans in close vicinity of the helipad. The reason is, in addition to the short NTM, practicing Crew Resource Management. Spending the daily routine together, from early morning exercises, run-ups of the helicopter, checking the medical equipment to watching TV at the evening, is important prerequisite for acceptance as an additional crew member. Therefore, the first days and weeks of deployment consisted of both: working off the Standard Operation Procedures (SOP) to be Combat Ready and becoming familiar with the team. The first included academics in Radio Communication, Emergency Egress and Aircraft Orientation, the second learning Football rules and celebrating Thanksgiving.
After academics and two training flights (one day flight, one under night vision goggles) both DEU EP were Combat Ready. We swapped our duty every 24 hours, unless the U.S. Flight Surgeon was on duty (every two to three weeks). After several turbulent years in Afghanistan, the 30th contingent (thank god) was “clear”. Nevertheless, the missions included cases starting by a broken finger up to an IED-Strike with several injured and dead. Between the missions, frequent “cold load” and “hot load” trainings with various Coalition Forces were performed. These training sessions helped to make sure that, during a real mission and especially in stressful situations everybody knew to act and handle appropriately. Hoist training and training flights (with or without night vision goggles) were further highlights during the deployment. The main purpose of the training flights for all crew members to train procedures for starting and landing the helicopter, especially in rough areas or in the mountains.
In addition to optimizing the treatment of emergency patients and being an Emergency Physician, the task was to gain experience for the implementation of individual DEU ForwardAirMedEvac-System. The German Armed Forces Medical Service is well prepared for these missions. The German Armed Forces features well-trained Physicians, highly educated and motivated Paramedics and provides durable and up-to-date medical equipment. To enhance future training of the DEU Physicians it has to focus on emergency medicine, including special skills. One of the reasons being that, when confronted with high numbers of patients the Physician has to have several skills for tasks that usually Paramedics perform. Additionally, they have to be able to work in a cramped, noisy and unstable environment in stressful situations.
Pre-hospital Trauma Life Support- (PHTLS) or Advanced Trauma Life Support- (ATLS) Provider levels not only strengthen individual knowledge and skills but also are very important for working in an international setting. A good command of English, especially a good knowledge of English medical terms, is important for picking-up patients from Coalition Forces as well as for continued work on helicopters of Coalition Forces, if required. Our DEU Paramedics do not have to shun comparison with U.S. Flight Medics; however, they need to graduate in PHTLS and should come with good knowledge of English, too. As a means of teambuilding, combined pre-deployment training for physicians and paramedics in a military hospital could be an advantage. The medical equipment of the U.S. ForwardAirMedEvac is comparable to ours. They use a Propaq-patient monitor and a Zoll-M-defibrillator, too. Only ventilators and electronic suction devices are built by manufactures not very familiar in Germany. This equipment is (surprisingly) very tough – during winter there might be snow inside a “Black Hawk” helicopter built in 1982…the equipment doesn’t care.
Even though the German Armed Forces Medical Service is well prepared for its own DEU ForwardAirMedEvac-System, we cannot fulfill the task on our own – we need suitable helicopters and qualified pilots. On the one hand, our pilots must have the ability to keep the NTM day and night, so technical and other directives should be adjusted to the reality of the deployment. And probably also Scramble-Procedures have to be re-evaluated. On the other hand, the whole Crew (including Physician and Paramedic!) has to be prepared to being deployed to “hot” landing zones with enemy contact.
Talking to U.S. pilots, you can hear a lot of respect for our DEU CH-53 Pilots, their experience and their flying skills. The helicopter model CH-53 is up-to-date. A new helicopter model (NH-90) is on the way and will (or better: has to) prove itself. Furthermore Coalition Forces look at the German Armed Forces Medical Service a little jealous since a long time. All in all: The German Armed Forces have got sufficient equipment and highly qualified and motivated soldiers, but we also have to know how to play the cards to make DEU ForwardAirMedEvac possible.
Dr. Andreas Otto
Military Hospital Westerstede, Dep. Anesthesiology and Intensive Care
DoB: March, 2nd 1983, Flensburg (Germany)
2003 – 2009: Study of Medicine, University of Lübeck
Since March 2010: Military Hospital Westerstede, Dep. Anesthesiology and Intensive Care
June 2011 - September 2011: 29th contingent DEU KFOR MTF Role 3, Prizren
November 2012 - March 2013: 30th contingent DEU ISAF MTF Role 2, Kunduz
Source: Medical Corps International Forum 2/2013
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