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Nursing and en route care: history in time of war.


In 1910, CPT George Gosman, US Army Medical Corps, modified an aircraft to show that casualties could be successfully transported in aircraft. However, there was no mention of an attendant. He then submitted a report to the Secretary of War describing this process. The report was not acted upon because it was felt that, although the need was compelling, the airplane was not sufficiently developed for such transport. (1) Between World Wars I and II, in 1920, 4 airplanes were modified to carry 2 litter patients and an attendant, and were used along the Mexican border.

After using this transportation for several Soldiers, an after action report stated "... no longer will the luckless injured recruit ... be jolted for hours in a rough ride automobile over cactus and mesquite, but borne on silvery wings, cushioned by a mile of air ... to the rest and comfort of a modern hospital." (1) (p5)

In 1921, the Army took delivery of a Curtis Eagle airplane that carried 4 litter and 6 sitting patients. Unfortunately, this airplane crashed, killing all seven on board, which halted any further development of aircraft for evacuation before World War II. (1) In 1930, a civilian pilot named Lauretta Schimmoler envisioned the idea of flight nursing. Out of this vision came an organization known as the Aerial Nurse Corps of America. This organization was founded independent of the military services, however, Schimmoler's intention was that her organization would provide flight nurses to the American Red Cross and the US Army. (2) Her ideas were not as acceptable to the American Red Cross and the Army as she had hoped, as shown in a response from MAJ Julia O. Flikke, Superintendant of the Army Nurse Corps from 1937-1943:
   ... any well-trained nurse to whom air travel is not
   distasteful, could be assigned, so that at present time at
   least there seems to be no factual justification for a
   group of nurses being segregated and called aerial
   nurses. (2) (p1177)

Later Schimmoler was informed that nurses would be assigned from the Army Nurse Corps for air evacuation, and further, members of her association could join the Army Nurse Corps which had many vacancies. In October of 1937, MG C. R. Reynolds, Surgeon General of the Army, discouraged the American Red Cross from organizing a corps of "flight nurses," since the Army did not see a need for specially trained nurses for air evacuation.


The Second World War brought about a significant change in the US Army's attitude toward the concept of "flight nursing" to accompany wounded Soldiers during air evacuation transport from forward surgical hospitals to tertiary facilities. Medical evacuation from the battlefield by air was brand new to the Army. Prior to the war, wounded were taken from the fight in trucks, field ambulances, and even the venerable old 2-wheeled handcart. The primary problem with these older forms of transport was the lack of speed in moving the injured to rear areas. Moving the wounded quickly to clean hospitals that had surgeons and life saving drugs--things that could not be found in an active combat zone--did lower the morbidity and mortality among battlefield casualities.

Increased use of airplanes in World War II made it necessary to train special nurses to accompany wounded men on evacuation flights to the rear. Standards and training were developed for flight nursing in response to the need. The first flight nurse training program was created at the Army Air Force School of Air Evacuation in Bowling Green Kentucky. (3) They learned crash procedures, received survival training, and learned the effects on patients of different altitudes. The first class of Army Flight Nurses, who were exceptional nurses that could pass a flight physical, completed training in February 1943. (3)

Following this class, air evacuation of patients began in North Africa and eventually became a standard. Medical evacuations with attending flight nurses flew in all theaters of operations during World War II. (4) The wounded troops were picked up from rear area hospitals, out of harm's way. Following the landings in Normandy (June 1944), medical transport C-47 airplanes, each with one flight nurse and one medical technician, were first flown into a hot combat zone in the European theater. These specially crewed airplanes eventually were deployed to every theater of the war. Over one million patients were evacuated by air during World War II. On one particular day, airplanes transported 4,707 wounded. All the wounded of World War I were returned to the United States on hospital ships or troop transport ships. During World War II, one-fifth of all patients returned to the United States by air evacuation. By the end of the war, the Army Air Corps had established 31 Medical Air Evacuation Transport Squadrons staffed by 500 flight nurses. (4)

Within the "chain of evacuation" established by the Army Medical Department during World War II, nurses served under fire in field hospitals and evacuation hospitals, on hospital trains and hospital ships, and on medical transport planes as flight nurses. The skill and dedication of these nurses contributed to the extremely low postinjury mortality rate among American military forces. Overall, fewer than 4% of American Soldiers who received medical care in the field and underwent evacuation died from wounds or disease. Rapid evacuation by airplane did lower the battle casualty fatality rate, but it cost the lives of 17 flight nurses.

Airplanes were scarce and valuable, so none were devoted entirely to medical evacuation. Airplanes for air evacuation also transported military supplies, and could not, under the Treaty of Geneva (also known as the Red Cross Treaty), display a red cross to indicate noncombat status. Without the red cross symbol, the evacuation flights were open to enemy attack. Due to the dual mission of the aircraft, there were frequent snarls in communication, sometimes causing nurses to fly into an area aboard a plane loaded with ammunition only to discover that there were no patients waiting to be evacuated. On the return trip, the empty plane and its crew remained vulnerable to an enemy attack. Equally frustrating to the nurses was the lack of emergency equipment on many evacuation aircraft. Further, many of the wounded patients had never been away from home before joining the Army, never been injured in combat, and never been on an airplane. Those factors combined with the 13-hour flight from Europe to New York to create a stressful environment for both patients and flight nurses.


These pioneering nurses assigned to field and evacuation hospitals as flight nurses became accustomed to taking the initiative, making quick decisions, and adopting innovative solutions to a broad range of medical-related problems. They learned organizational skills by setting up and moving field and evacuation hospitals while following the troops. They developed teaching and supervisory skills while training the medics under their command. Paperwork no longer intimidated them, as circumstances forced them to deal with increasingly complex administrative chores. This legacy of flexibility, dedication, and professionalism set the standard for all who have followed.


During the Korean War which began in 1950, nurses were the only female military personnel allowed to serve in the combat zone. From 1950 to 1953, nurses served aboard ships, in mobile surgical hospitals and even on hospital trains and MEDEVAC flights. Due to terrain that was rugged, primitive, and forbidding, evacuation of the wounded by ground transportation during the Korean War was very difficult. The "chain of evacuation" medical doctrine was a holdover from World War II, and only included fixed-wing aircraft. However, since practical, reliable rotary-wing technology had been developed prior to the Korean War, it was the first military conflict in which helicopters were available in significant numbers. Early in combat operations, it was demonstrated that the helicopter could evacuate wounded Soldiers by air directly from the battlefield environment for the first time. On August 5, 1950, a US military helicopter supporting combat operations in Korea responded to an emergency call and transported a wounded Soldier to a mobile army surgical hospital. In an after-action report, the hospital commander stated:
   ... the helicopters proved to be well worth their cost for
   use in removing patients from the front ... making a
   fifteen minute air trip which would have been several
   hours by ground ambulances from the front to this
   hospital. (5)

Their value in rapid evacuation from the point of injury to advanced medical care was quickly recognized, and helicopters were dedicated as medical assets, ultimately transporting approximately 20,000 patients. (5) In November 1952, The Surgeon General of the Army activated an aviation section to strengthen medical control over MEDEVAC. (5)


During the Vietnam conflict, approximately one million patients were transported by helicopter. (6) When placed in MEDEVAC operations, the Bell UH-1 helicopter was large enough to hold patients and have medical personnel provide care during the flight to the field hospital. In limited cases, nurses traveled with MEDEVAC patients but no records exist to describe to what extent this occurred, and no nurse training program was created to address helicopter transport. However, the value of helicopter transport of patients was firmly established and shown to positively impact the survival rates of wounded Soldiers. (7)


Medical evacuation of casualties has come a long way since World Wars I and II, Korea, and Vietnam. Technology advances and systems have responded to the ever-increasing complexity of modern warfare. The battlefield of the past with clear lines of demarcation has been replaced with a combat zone that spans wide areas, including towns, cities, and the home base of operations.

In today's combat theater, level I care is typically provided by the first responder at the point of injury, the medic that is assigned to a unit and its organic battalion aid stations. Level II care includes initial emergency resuscitative and stabilization surgery, coupled with life and limb saving actions. The level II facility, the forward surgical team (FST), provides a mobile surgical capability as close to combat operations as possible. Level III provides essential care within theater, characterized by the combat support hospital (CSH). The core of ensuring quality health care to our forces and the key to success is the ability to continue treatment started at levels I and II, and evacuate the wounded to definitive health care while maintaining stabilization and providing emergency intervention during the medical evacuation.

Transporting wounded Warriors quickly through the echelons of care is vital, delays in their receipt of more definitive life-saving care can lead to loss of life or limb. En route care occurs between levels II and III, and beyond--level III to level III, and out of theater, involving Air Force evacuation airplanes.

The need to transport postsurgical critical patients by helicopter first arose with the development of the FST. Patients treated at these facilities often must be transported while recovering from surgical intervention and are in critical condition. These patients are often intubated and on vasoactive intravenous medications that require monitoring by medical personnel trained in critical care. The condition of this type of patient is beyond the original mission concept of MEDEVAC, which emphasizes quick movement of multiple, newly injured patients rather than the transport of one or 2 patients requiring advanced monitoring and significant medical equipment. Such care for critical, postsurgical patients requires skills not normally found in EMT-level personnel. The transfer of patients from an FST or CSH with only the attendance of an EMT-trained medic could seriously decrement the level of care. Specialized nursing skills are required to support these missions due to the high acuities of the transported patients.

The requirement for critical care personnel in the MEDEVAC mission became obvious during the conflicts in Bosnia-Herzekovina and Kosovo, beginning in 1997. In operations supported by the 67th FST, the critical patients were moved from the FST to the Mobile Aeromedical Staging Facility accompanied by advanced cardiac life support trained personnel. These operations were continued with the arrival of the 67th CSH. The problems with the need for nonstandard medical equipment on helicopters and the limited availability of critical care personnel continued throughout operations in those conflicts.

Since early 2003, Army nurses have functioned as en route care providers in numbers not seen before due to the high number of critical patients being transported within the theaters of Iraq and Afghanistan. Approximately 20,000 aeromedical missions were conducted from 2003 to 2010, with two thirds requiring provision of critical care. (8) Approximately 20% of those missions moving patients between level II and level III facilities, or level III and level III were supported by nurses. The Army nursing en route care program evolved in Operation Iraqi Freedom from 2006 to 2009, and the challenges of these missions remain the same in Iraq, Afghanistan, and other overseas contingency operations.


In 2002, senior Army nursing leadership advised the Chief of the Army Nurse Corps, BG William Bester, of the gap in critical care management during aeromedical transfers in helicopters in the new combat environment of Afghanistan. As the battlefield stretched with expanded rapid access to FSTs and split-based combat support hospitals for damage control resuscitation and surgery, the need for critical care postoperative and advanced clinical management during patient transport became increasingly obvious, especially with the initiation of combat operations in Iraq. This gap was directly attributed to a skill-to-requirement mismatch in the clinical training of Army flight medics. While the flight medics were given a significant foundation in point of injury, trauma, and acute medical evacuation management, they did not have sufficient capability to provide the advanced critical care management required during interfacility transfers.

Under BG Bester's guidance to address this issue, one Critical Care Nurse was assigned to the Army School of Aviation Medicine at Fort Rucker, Alabama. Over the next 3 years, the Joint En Route Care Course (JECC) was developed and implemented. The JECC provides concise, realistic, relevant, and current training on en route trauma transport to care providers involved in aeromedical helicopter operations. A 14-member board of subject matter experts consisting of flight medics, helicopter pilots, nurses, and physicians from the Army, Navy, and Air Force convened to review and validate the course in 2006.

The course consists of 10 days of mentally and physically challenging training, with a focus on providing didactic and practical applications of advanced aeromedical and trauma management concepts, effective communications, and roles. These duties are integrated into safe operational performance in a combat environment in a tactical helicopter. The course includes trauma team concepts taught at the Army Trauma Training Center in Miami, Florida, and accepted as best practices in trauma centers throughout the United States.


As Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) evolved, intheater units addressed problems with en route care as they arose. From October 2005 to October 2007 in OIF, the 30th Medical Brigade addressed concerns with the medical regulation of MEDEVAC patients, equipment issues, standardization of care for neurological patients, and packaging patients for flight. They reported that 10% to 20% of patients required inflight emergency intervention by the nursing personnel. The efforts of the 30th Medical Brigade were continued and expanded by succeeding units. Those local efforts began to be integrated into existing programs and concepts for the Army Nurse Corps.

In 2007, as part of their efforts to standardize and improve trauma care in theatre, the Joint Theatre Trauma System (JTTS) developed an Intratheater Transport Clinical Practice Guideline (CPG) in collaboration with subject matter experts in Army medicine. This document established guidelines for transporting critical patients and serves as a guide for nurses providing en route care. The CPG states that polytrauma patients require medical management beyond flight medic capability, and recommends that a physician or nurse with critical care experience manage these patients. (9)

During the years of the surge in Iraq (2007-2009), there was an increase of critical injured patients. In response, the 62nd Medical Brigade tasked the 86th CSH to standardize and measure the effectiveness of en route care. Nursing-related patient outcomes were measured and tools were developed to capture nursing workload. The metrics included interventions during transport, equipment issues, and clinical performance improvement initiatives which were used to determine priorities and improve care. These initiatives attempted to create a system of evidence-based care and workload-driven staffing that is normally conducted in medical treatment facilities. The selections of these metrics were based on the clinical recommendations of the JTTS.

Data collected and analyzed during the period 20072009 clearly showed that nursing was making a difference in patient outcomes as measured by reductions in hypothermia, acidosis, and mortality. Nurses were performing critical interventions, such as managing hemodynamic changes, making adjustments in ventilator settings, or troubleshooting critical medical equipment approximately 70% of the time. This data validated the need for critical care nurses in the provision of en route care for postsurgical and other critical patients transported between level II and higher capability medical units.


The surge of casualties resulting from recent events in Afghanistan have stimulated significant improvements in the process of en route care. Task Force 62 Med (OEF 2010) created several initiatives that drew upon past efforts to standardize en route patient care. Among those improvements are further definition of the qualifications of en route care nurses, dedication of nursing personnel to this specific mission, and integration of the medical brigade, JTTS, and the Joint Combat Casualty Research Team (JC2RT) efforts in tracking data for the purpose of performance improvement. The initial finding of JC2RT indicate that the en route critical care nurses are instrumental in maintaining homeostasis in the acute post-damage-control resuscitation/surgical transfer patients, as measured by oxygenation, through advanced airway management and advanced intravenous pharmacological support, such as vasoactive, analgesic, sedative, and paralytic medication management. Further, the assignment by Task Force 62 MED of nursing personnel to the aviation brigade and MEDEVAC units improved casualty care through ongoing training of flight medics by critical care nurses, and resulted in a team-based care environment.

Currently, the Army has significantly revised and improved training nurses in trauma care. A new trauma nursing training program, the 66T Area of Concentration course, has been implemented to train nurses in critical and emergency care of trauma patients. This program has included en route care in its curriculum, and its graduates will be able to apply the lessons learned to future en route care missions.

The future of en route care requires a flexible response to changes in both combat conditions and patient needs. This will require collaboration among medical personnel and their skills sets; development on new capability through training, data collection and analysis to develop evidenced-based care; and the allocation of appropriate equipment and resources. The collaboration of skill sets and the improvement of patient outcomes has been a successes of the en route care program. (8)

Army nursing has been integral in the improvement of patient outcomes through the provision of essential skills in critical care, and through data collection and analysis. The analysis of the data collected will foster a learning environment in which best practices will emerge as supported by evidence. These practices will continue to promote standardized training and preparation for en route care nurses, allowing such trained critical care nurses to deploy to use their skills, knowledge, and abilities in caring for those critically injured as they are transported to higher echelons of care. Army nursing will continue to be in the forefront of "aerial nursing" as it has been since World War II when Army Nurses stepped forward to fill a capability gap. In so doing, they established and developed an entirely new discipline, dedicated to the survival and care of our wounded Warriors as they are rushed from the battlefield to the highest echelons of medical care.


(1.) Whitcomb D. Call Sign-Dustoff: A History of U.S. Army Aeromedical Evacuation from Conception to Hurricane Katrina. Fort Detrick, MD: Borden Institute, Office of The Surgeon General, US Dept of the Army; 2011.

(2.) Barger J. Origin of flight nursing in the U.S. Army Air Forces. Aviat Space Environ Med. 1979;50 (11):1176-1178.

(3.) Stroup LB. Aero-medical nursing and therapeutics. Am J Nurs. 1944;44(6):575-577.

(4.) Harl V. WW II Flight Nurse. Available at: http:// Accessed September 15, 2011.

(5.) Driscoll R. US Army helicopters in the Korean War. Mil Med. 2001;166(4):290-296.

(6.) Howard WG. History of Aeromedical Evacuation in the Korean War and Vietnam War [master's thesis]. Fort Leavenworth, KS: US Army Command and General Staff College; 2003. Available at: http:// Accessed August 25, 2011.

(7.) Mabry RL, De Lorenzo RA. Sharpening the edge: paramedic training for flight medics. US Army Med Dep J. April-June 2011:92-100.

(8.) Hudson TL, Morton R. Critical care transport in a combat environment: building tactical trauma transport teams before and during deployment. Crit Care Nurse. 2010;30(6):57-66.

(9.) US Army Institute of Surgical Research. Intratheater Transfer and Transport of Level II and III Critical Care Trauma Patients. November 2008. Available at: Accessed August 25, 2011.

MAJ R. Scott Davis, AN, USA

COL Linda K. Connelly, AN, USAR

MAJ Davis was a Trauma Nurse Coordinator for the Joint Theatre Trauma System, Operation Enduring Freedom, from April 2007 to October 2007, and Operation Iraqi Freedom from April 2009 to October 2009. He is currently assigned to the Office of the Chief, Army Nurse Corps.

COL Connelly was the Deputy Commander of the 345th Combat Support Hospital from April 2008 to May 2009. Currently she is the Deputy Chief, Army Nurse Corps, Drilling Individual Mobilized Augmentee.
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Author:Davis, R. Scott; Connelly, Linda K.
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2011
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