New Air Force concept for aeromedical evacuation to meet challenges in Africa

From left, Lt. Col. Jerry Fortuna, Master Sgt. Jose Arias-Patino, and Lt. Col. Rick Dagrosa, stand next to a C-130 aircraft parked on the flight line at Ramstein Air Base, Germany. The airmen are part of a specialized aeromedical evacuation team, created to address the gaps in frontline medical care in Africa.


By JENNIFER H. SVAN | STARS AND STRIPES Published: December 26, 2013

RAMSTEIN AIR BASE, Germany — They were put on alert during the most recent anniversary of the Sept. 11, 2001, terrorist attacks.

If the call came, the Air Force’s newest aeromedical evacuation team members would head for the designated C-130 or C-17 waiting on the Ramstein tarmac, grabbing duffel bags of surgical tools and other equipment from a warehouse and embarking on a race against time and distance.

The surgeon, emergency medicine physician, two nurse anesthetists and an operating room technician — Air Force personnel assigned to Landstuhl Regional Medical Center — would augment other aeromedical crews, on a mission to Africa to pick up injured Americans, fly them back to Germany and, if necessary, operate prior to takeoff or while en route.

Airlifting wounded or sick troops is nothing new for the Air Force, which has transported more than 150,000 patients to higher echelons of medical care during the wars in Iraq and Afghanistan, helping to push the odds of surviving a combat injury to about 98 percent.

Air force aeromedical evacuation crews routinely move critically ill troops after they’ve been stabilized or received damage-control surgery. But they haven’t, as a matter of course, performed that surgery on a moving aircraft or airlifted over long distances patients not medically cleared for flying.

The Air Force is preparing to do just that, if the need arises, in Africa, where frontline medical care isn’t always available or a safe option in some of the more remote, dangerous locations in which U.S. personnel sometimes work.

U.S. Air Forces in Europe recently established the Tactical Critical Care Evacuation Team — Enhanced, known as TCCET-E for short. It can perform “patch ‘em up type surgeries,” before takeoff or while in flight, said Col. Jay Neubauer, USAFE’s command surgeon.

The concept, a collaborative effort between USAFE and Air Mobility Command, which oversees the service’s vast aeromedical evacuation mission, evolved out of the Air Force special operations community, Neubauer said.

“They’ve been thinking of ‘how do we solve these issues of getting patients out of very austere locations’ for a while,” he said.

It’s a new concept for in-flight medical care the Air Force plans to adopt in other regions of the world, but is particularly suited for the current challenges in Africa, Neubauer said.

“As we look at future war and the shift to the Pacific, we’re looking at an environment where we may not have the great access we’ve had in Afghanistan and Iraq,” Neubauer said. He was referring to the network of field hospitals and major trauma centers throughout those two war zones that enabled the U.S. military to treat the wounded much faster and to reduce the combat-related mortality rate.

“We took that concept and said, ‘Wow, Africa fits,’” Neubauer said. “In some very specific situations it may be helpful for us to have a team that can go in with lots of capability, grab somebody up fairly quickly and move them out, back to Europe.”

Given the vastness of the African continent, coupled with the small U.S. presence and lack of organic medical facilities and airlift assets in country, the model of medical treatment employed in Iraq and Afghanistan isn’t feasible, Neubauer said. With U.S. military personnel often working in isolated, sometimes dangerous areas, far from adequate host nation hospitals, the result is a gap in frontline medical care, he said.

Benghazi is a case in point — sort of.

At a medical conference in London this fall, Neubauer spoke about the Sept. 11, 2012, attack on the U.S. consulate in the volatile Libyan city, where the U.S. ambassador and three other Americans were killed.

“On that day we found that we could not respond quickly enough — either to fight or to move critically ill patients,” Neubauer said at the Oct. 16 conference, according to IHS Jane’s Defence Weekly.

Survivors of the attack, including three wounded personnel, were airlifted from Tripoli to Germany nearly 24 hours after the first attack on the consulate’s compound began, according to news reports at the time.

The incident “gave us the requirement to develop a capability to respond quickly to needs throughout Africa, particularly at embassies, including a ‘911’ medical and evacuation capability,” Neubauer said, according to the Jane’s article.

But in a recent interview, Neubauer played down that assessment.

“This really wasn’t about Benghazi. Certainly, we’ve had some new requirements placed upon us because of the events of Benghazi,” Neubauer said, declining to discuss specifics. “This is all about looking towards the future and the capabilities we’re going to need for the potential next war.”

TCCET-E enhances the Air Force’s tactical critical care evacuation team — a three-member team that provides emergency trauma care in mostly rotary-wing aircraft — with a surgical capability, and places the expanded crew on a fixed-wing aircraft to give it wider range, Neubauer said.

The five-person TCCET-E crew would also fly with the standard aeromedical evacuation crew as well as the Air Force’s Critical Care Air Transport Team, which operates an intensive care unit in the aircraft cabin during flight for patients who have been stabilized but are still critically ill. One of those teams treated a servicemember wounded in the Dec. 21 attack on U.S. military aircraft involved in evacuation efforts in South Sudan, according to Pentagon officials.

“The current capability has those critical-care specialists who can do IVs, ventilators and specialized equipment and adding on a surgical capability, so we can do some damage-control surgery, if somebody needs that while we’re moving them,” Neubauer said.

It’s akin to bringing an airborne emergency department to near the point of injury, said Lt. Col. Rick Dagrosa, an emergency room physician and medical director of the Landstuhl Regional Medical Center emergency department, who’s one of the five TCCET-E members.

“We can actually bring a surgical suite to the battlefield … to help folks,” he said, “and that’s something that didn’t exist before.”

But there are limitations, the obvious and biggest being time and distance, said Lt. Col. Jerry Fortuna, the TCCET-E team leader and LRMC’s chief of general surgery.

One reason the survivability rate in Afghanistan is nearly 99 percent is the ability to provide medical treatment within an hour of a serious injury, Fortuna said.

With Africa being hours away from Germany, the team won’t be able to provide treatment in all cases within that “golden hour,” he said.

“There is a time and distance issue and there are physiological issues with the patient. The two are not a perfect marriage — but it is better than not receiving surgical intervention at all. Like any tool, it has a purpose and it has limitations.”

Though the team would travel with 10 times or more of the amount of blood products than packed on a typical aeromedical evacuation flight, patients with severe bleeding could be out of the team’s reach because of response times.

Hemorrhage control — stopping bleeding from a traumatic injury — “which is the biggest cause of fatality on the battle space is probably still going to be a problem for patients that we are responding to,” Fortuna said. “I think it’s important to recognize that anybody who suffers a massive injury and they’re losing a lot of blood that can’t be controlled with a tourniquet are probably not going to do well waiting for six to nine hours to get surgical capability to you. That’s a limitation of this platform.”

The team could help stabilize fractures that may accompany vascular injuries, Fortuna said, or treat a patient with abdominal problems, for example.

Maintaining a sterile environment inside the aircraft cabin and dealing with turbulence in-flight present other challenges, but not insurmountable ones, Fortuna said.

More daunting is figuring out which patients need to go the surgical side of the aircraft cabin “versus the other side,” Dagrosa said. “We don’t know a whole lot about the situation we’re picking up, and then going through and figuring out which few of those patients need to go to” the team’s surgeon, Fortuna.

The team would fly with security personnel, Fortuna said. “There may be activity ongoing in the area. These aren’t places where you want to go and linger. It’s a scoop-and-go type mission,” he said.

The team would be “tethered” to the aircraft, he said. “If you want to make it out of where you’re at, you need to be able to get on the plane where it lands.”

USAFE is in the process of getting a second TCCET-E team trained, Fortuna said.

“Nobody at present is sitting on continuous alert like pilots waiting for a phone call,” Fortuna said. “But we definitely are tracking each other to make sure we are within a reasonable response time should we be asked to respond to anything.”


From left, Lt. Col. Jerry Fortuna, Master Sgt. Jose Arias-Patino, and Lt. Col. Rick Dagrosa, stand next to a C-130 aircraft parked on the flight line at Ramstein Air Base, Germany. The airmen are part of a specialized aeromedical evacuation team, created to address the gaps in front-line medical care in Africa.