Registered nurses as permanent members of medical evacuation crews: the critical link.
Successful evacuation of patients throughout the ensuing interval of relative peace proved the concept of dedicated aircraft and reinforced the use of enlisted flight medics to attend to the evacuees. While indicators were present shortly after the first employment of forward surgical teams (FSTs) in Bosnia-Herzegovina and Kosovo in 1997, (1) the return of Army nurses to the chain of evacuation actually became a necessity as combat operations intensified in Operations Enduring Freedom and Iraqi Freedom. Advances in body armor and battlefield medicine, coupled with the capabilities of nearly ubiquitous FSTs, led to unprecedented survival rates. Patients transported by theater medical evacuation assets were more care-intensive, requiring titration of vasoactive medications, sedative infusions, and paralytic agents while manipulating mechanical ventilation. At times, resuscitation was required en route. (3) Clinicians with critical care experience became a requirement for these evacuations.
As the executive agent for medical evacuation in theater, the Army must ensure the standard of care provided to the Soldiers, Marines, Sailors, and Airmen is the best available. To fulfill this clinical requirement, the best option is to assign Army nurses to medical evacuation helicopter units as nonrated members * of flight crews.
Army nurses on the crew will undoubtedly help to ensure evacuees receive the best care achievable in theater, from the point of injury to the combat support hospital.
EN ROUTE CRITICAL CARE
Few statistics exist to demonstrate the need or effectiveness of intratheater critical care evacuation early in Operations Enduring Freedom and Iraqi Freedom. However, some information can be inferred from US Air Force intertheater data, which shows that from 2003 to 2006, the Air Force evacuated a total of 37,000 patients from the US Central Command area of operations. Of those, 6,800 were battle injuries and 500 required Air Force critical care air transport team involvement. (2) A logical extension of that data indicates that Army critical care nurses and physicians were likely involved in the intra-theater evacuation of at least 500 critically ill evacuees.
Early in Operation Iraqi Freedom, medical leaders in the theater of operations recognized that patient conditions were well beyond the scope of the original medical evacuation concept, which allowed for patient attendance by a single emergency medical technician-trained medic, and put the critically ill patient at serious risk for potentially lethal complications. (1) To mitigate this unforeseen risk, critical care nurses and physicians with little knowledge of aeromedical operations augmented the medical evacuation crews, sporadically and unofficially, providing the care necessary to successfully transport the patient to the next level of care. By 2006, the Army developed the Joint En Route Care Course (JECC) to provide "concise, realistic, relevant, and current training on en route trauma transport to care providers involved in" medical evacuation operations. (1(p48)) Graduates of the JECC (generally experienced critical care or trauma nurses, physicians, and licensed practical nurses) were prepared to care for the critical patient in the cramped, noisy environment of a medical evacuation helicopter.
As critical care clinicians became more involved in the medical evacuation process, quality improvement measures and patient outcomes measures were implemented to further understand the impact of this new role in the chain of evacuation. In October 2005, the 30th Medical Brigade began tracking medical evacuation statistics. As the senior medical command in Iraq, the brigade reported that 10% to 20% of all medical evacuation patients between October 2005 and October 2007 required some sort of in-flight emergency intervention. (1) The 62nd Medical Brigade and the 86th Combat Support Hospital gathered data on evacuations in Iraq from 2007 to 2009.1 Over a 15-month period of time, over 700 patients required critical care escort during intra-theater evacuation. Between September 2007 and September 2008, Army nurses provided en route care in approximately 60% of all medical evacuation missions. (5) In nearly 10 years, from the beginning of operations in Afghanistan and Iraq until 2010, the Army conducted more than 20,000 medical evacuation flights in support of combat operations. (1,3) Two-thirds of these flights were in support of "preoperative and postoperative resuscitation or surgery patients who had received care at a [FST] or combat support hospital." (3)
As combat operations in Iraq and Afghanistan continued, it became obvious that more patients were critically ill at the point of injury and required greater care during intra-theater transport. In 2004, the US Army Institute of Surgical Research established a clinical practice guideline (CPG) that details the roles and responsibilities of personnel assigned to establish intra-theater medical evacuation. According to the CPG, the goal of intra-theater evacuation is to "provide every patient who is injured on the battlefield or in the AOR [area of operations], the optimal opportunity for survival and the maximum potential for a functional recovery." (6) The operational environment had changed over the years between the Vietnam conflict and Operation Iraqi Freedom. American military prowess could not be matched. The enemy, seeing no other recourse, adopted a guerilla-style warfare that hinged on the use of improvised explosive devices (IEDs) to injure the relatively well-protected American military member. The employment of IEDs resulted in types of polytrauma patients unseen in previous American conflicts who required a higher level of care than normally provided by medical evacuation teams of the past. (6) To account for this change in patient severity, the Army Medical Department (AMEDD) implemented changes to provide more appropriate care to evacuated patients, beginning at the point of injury (POI).
PARAMEDIC CREW MEMBERS
Currently, all US Army flight medics are trained as an emergency medical technician-basic (EMT-B), which is supplemented by training in prehospital trauma life support. In 2011, Mabry and De Lorenzo posited that paramedic training would greatly enhance the role of the flight medic in providing initial care to those who suffer combat injuries. They proposed a 32-week training cycle that incorporated the flight medic course at Fort Rucker, Alabama, emergency medical technician paramedic (EMT-P) training, and a ride-along program with civilian air ambulance services in the San Antonio area. (7) By September 2011, the Army had announced a $53 million plan to implement the Mabry and De Lorenzo concept, citing data which demonstrates that patients treated by Army National Guard flight medics, many of whom are also civilian flight paramedics, have a 66% higher survival rate. (8)
While the EMT-P program serves to fill the patient care gap identified by the AMEDD, and it provides a level of clinical education to match the combat experiences of current Army flight medics, some concerns arise about the efficacy of the Soldiers trained in this program. The civilian version of the EMT-B course is a 120-hour program focused on stabilization and transport. The civilian version of the EMT-P course is a 1,000-hour program that focuses on stabilizing medical and traumatic conditions as well as correcting the underlying clinical abnormalities. The Army National Guard flight medics who are civilian paramedics likely have several years of paramedic experience and would be well-versed in polytrauma critical care. Generally, to be hired as a civilian flight paramedic, one must demonstrate a significant amount of ground-based experience. For example, a recent employment announcement by Hahnemann University Hospital in Philadelphia for flight paramedics specified that applicants must have a minimum of 5 years experience as a paramedic for consideration of a job application. (9) According to the National Registry of Emergency Medical Technicians, "paramedics represent the highest licensure level of prehospital emergency care in most states." (10) Without this extensive experience, novice paramedics may question their skills or miss the minute indicators that can lead to a detrimental patient outcome if not addressed. Their experiences and the time it takes to develop their skills in the civilian sector cannot be replicated in an EMT-P program of the AMEDD Center and Schools. Therefore, that success rate is an inappropriate benchmark for the newly-minted, EMT-P certified Army flight medic.
As the pace of the operational environment slows and deployments decline, the EMT-P flight medics will have fewer opportunities to remain clinically prepared for combat medicine. In the United States, some EMT-P trained flight medics will have the opportunity to take part in evacuations from POI to a medical treatment facility because they are assigned to remote posts or to training facilities. Most flight medics, however, are assigned to units or posts where civilian medical evacuation capabilities cover the region. In the majority of geographic locations of large US Army installations, it will be difficult for EMT-P flight medics will struggle to gain the requisite clinical experience through ride-alongs and emergency room exposures. In those metropolitan healthcare markets that allow the needed ride-along experience, many restrict the ability of the observer to medically interact with the patient due to medical-legal considerations, thereby limiting the usefulness of such a program. This may be mitigated somewhat by assigning the flight medic to the medical facility-based emergency medical service on the Army post as borrowed manpower, fulfilling an advanced life support role on the ambulance service. Even this experience, however, provides little comparable experience for the combat oriented flight medic as the Army emergency medical service generally has less trauma-focused work than a civilian air ambulance service.
REGISTERED NURSES ON EVACUATION CREWS
There is little question that the EMT-B trained flight medic is inadequately trained for today's combat medical environment. The EMT-B training does not meet the scope and depth of clinical practice required in today's environment. (1) Paramedic training helps fill this gap, but the limited clinical experience available to the new EMT-P flight medics and the difficulty of keeping their skills current prevents EMT-P flight medics from being the ideal answer. In 70% of en route care provided in Iraq from 2007 to 2009, nurses were required to perform critical care interventions that are beyond the experience level of EMT-P trained flight medics. (1) A position paper published by The Air and Surface Transport Nurses Association states:
The Air & Surface Transport Nurses Association (ASTNA) believes that services providing critical care transport are functional extensions of hospital emergency departments, and specialty/critical care units. ASTNA further believes that staffing for these services minimally consist of at least one professional, registered nurse who has completed training specific to transport and possess extensive experience and expertise in caring for critically ill and injured patients. Finally, ASTNA believes that nurses employed by critical care transport services who respond to and transport patients from the scene of injury should have training in the unique aspects of prehospital care. (11)
Wirtz et al (12) published a study of civilian medical evacuation crews which compared the outcomes of nearly 1,200 patients cared for by nurse/nurse crews and nurse/ paramedic crews (a paramedic/paramedic crew does not exist in the civilian sector and therefore was not included in the study). The study found no statistically significant difference in patient outcomes among the crews, reinforcing the paradigm that the typical flight crew should consist of at least one critical care or trauma trained registered nurse.
The seasoned Army critical care or trauma nurse (hereinafter referred to by their area of concentration designation 66HM5/8A) brings a level of clinical expertise rarely seen in a paramedic. The 66HM5/8A has undergone a 4-month course in emergency and/or critical care nursing and developed many of the clinical problem solving skills that comes with being a registered nurse, in addition to the critical thinking skills gleaned through 4 years of undergraduate study. Critical care experience does not end with completion of the emergency and/or critical care course. After the course, 66HM5/8As are mentored for 6 months prior to being eligible for deployment. This ensures that most 66HM5/8As have nearly 2,000 hours of didactic and clinical experience before being deployed, and ensures that they have developed the instincts necessary to discern subtle changes in the back of a cramped, loud helicopter. Army Nurses who hold the 66HM5/8A designator serve in the critical care or emergency setting and maintain that clinical expertise on a daily basis. Seldom are they removed from the clinical mission for training purposes, counter to the reality that enlisted medics (EMT-B or EMT-P) experience on a daily basis. For nurses, daily clinical exposure is the norm, rather than the exception.
It is time for Army nurses to become permanent, nonrated members of Army medical evacuation crews. In today's Active Army, there are approximately 20 medical evacuation units staffed with EMT-B flight medics. To augment these units with the addition of one permanent 66HM5/8A per unit would require approximately 20 Army nurses from the AMEDD. The critical nature of patient care in the aircraft requires the daily presence of nursing expertise. This nurse, acting as the senior critical care expert in the medical evacuation unit, is a clinical expert who can provide an unparalleled level of care for the patient and may also serve as a clinical advisor to the unit.
Army nurses, by the nature of their profession, are educators. While the aviation flight surgeon assigned to the medical evacuation unit is available for staff education and patient care, he or she is often not as experienced in the care of critically ill patients. The flight surgeon is generally focused on maintaining the health of the medical evacuation crew. The 66HM5/8A would focus on educating and training the flight medics, as well as facilitating a medical proficiency training program at the local medical treatment facility, in preparation for their clinical role on the crew. The 66HM5/8A, who would split their time between keeping their skills current in a medical treatment facility and maintaining their flight currency (just as other Army Forces Command (FORSCOM)-assigned Army nurses do already), has the ability to facilitate clinical experiences for the flight medics in the emergency department, the critical care units, and the operating room. These efforts alone could justify the assignment of a 66HM5/8A to the medical evacuation units.
Deployment in support of combat operations is mentally and physically taxing on even the most seasoned military members. A single 66HM5/8A in the medical evacuation unit would not be able to withstand the intensity of the situations that require medical evacuation. The permanent 66HM5/8A would need augmentation through the AMEDD Professional Filler System (PROFIS), * adding an additional 5 or 6 nurses per medical evacuation unit, which would provide for a rotation of the 66HM5/8A in shifts with the accompanying flight medics. To reduce the total flight nurse requirement, the flight nurses could be deployed at half of the total expected requirement. Medical evacuation helicopters tend to work in tandem, allowing one flight nurse per pair of aircraft, which would reduce the overall PROFIS assignment requirement. To prepare for their new assignment, these PROFIS 66HM5/8As must attend the Combat Casualty Care Course and the Joint En Route Care Course, just as the assigned FORSCOM nurse, prior to arriving at the unit. Most senior company grade nurses already attend these courses prior to deployment, so this would not require a new process or cost increases associated with training. Prior to deployment, the PROFIS 66HM5/8A would join the unit for rotations at the Combat Training Centers at Fort Irwin, California or Fort Polk, Louisiana, where they would become familiarized with the unit's standard operating procedures, equipment, and personnel. These rotations would help integrate the 66HM5/8A into the close-knit community of aviation medicine and allow flight crews to become familiar with the nurses' clinical capabilities.
Some may argue that Army nurses are not prepared to be a part of the medical evacuation flight crew, conducting patient care at the point of injury in a potentially hostile fire environment. Army Medical Department members receive extensive training throughout their careers in preparation for deployments to a combat zone. Once assigned to the position, to ensure their preparation for the medical evacuation mission, the 66HM5/8A should attend the Combat Casualty Care Course and the Joint En Route Care Course. The former is designed to give personnel the skills necessary to provide medical care under austere conditions. The latter provides attendees with a 2-week foundation in the fundamentals of operating in and around helicopters while also introducing experiential clinical learning based on the most current lessons learned from the CENTCOM theater of operations. Additionally, the 66HM5/8A will take part in multiple training exercises with the aircrew upon assignment to the team, gaining familiarity with the aircraft and the standard operating procedures of the crew.
With fewer deployments anticipated in the future, and budget constraints a persistent reality, the $53 million program to train EMT-P may be too costly to sustain. Use of the 66HM5/8A as a permanent member of the aircrew takes advantage of 3 programs of instruction already present in the AMEDD. In addition, because Army nurses are regularly involved in direct patient care, the skills and knowledge needed by a flight nurse are more easily sustainable than those required of a paramedic-trained flight medic. Furthermore, 66HM5/8A registered nurses who are assigned to medical evacuation units improve patient care throughout the unit by training the flight medics and fostering a team-based care environment. (1)
Medical evacuation has changed from the experiences of the past decade of combat operations. Much of the focus of medical support in the combat zone is now critical care during evacuation, which is, and will continue to be, a very successful, life-saving asset. (2) The assignment of Army critical care or trauma nurses to medical evacuation units is consistent with the recognition that the medical evacuation system is a truly vital asset in the success of today's American military. Our NATO allies, and our sister services, rely heavily on the availability, reliability, and especially the continuity of care of the Army medical evacuation system. (5,13) It is time to upgrade the system of evacuation and provide our Warriors with the greatest possibilities of survival. Army nurses trained in critical care and trauma nursing are best suited to provide that continuity of care.
(1.) Davis RS, Connelly LK. Nursing and en route care: history in time of war. US Army Med Dep J. October-December 2011:45-50.
(2.) Roedig E. Aeromedical evacuation. Technical evaluation report summarizing the proceedings at the NATO specialist meeting 157, 2-3 December 2008, in Sieburg, Germany. North Atlantic Treaty Organization; 2009. Available at: ftp://ftp.rta.nato. int//pubfulltext/rto/mp/rto-mp-hfm-157/. Accessed May 4, 2012.
(3.) Hudson TL, Morton R. Critical care transport in a combat environment: building tactical trauma transport teams before and during deployment. Crit Care Nurse. 2010;30:57-66.
(4.) Army Regulation 600-106: Flying Status for Nonrated Army Aviation Personnel. Washington, DC: US Dept of the Army; December 8, 1998:9.
(5.) Nagra, M. Optimizing wartime en route nursing care in Operation Iraqi Freedom. US Army Med Dep J. October-December 2011:51-58.
(6.) US Army Institute of Surgical Research. Intra-theater Transfer and Transport of Level II and III Critical Care Trauma Patients. November 2008. Available at: http://www.usaisr.amedd.army.mil/assets/ cpgs/Intratheater_Transfer_and_Transport_19_ Nov_2008.pdf. Accessed May 4, 2012.
(7.) Mabry RL, De Lorenzo RA. Improving role I battlefield casualty care from point of injury to surgery. US Army Med Dep J. April-June 2011:92-100.
(8.) Zoroya G. Top-flight medics: Army training moves to next level. USA Today. September 6, 2011. Available at: http://www.usatoday.com/news/military/story/2011-09-06/Top-flight-medics- Army-training-moves-to-next-level/50286806/1. Accessed May 4, 2012.
(9.) Tenet Healthcare Corporation. Job Search: Flight paramedic-fulltime-med evac-841-7365-1205006 939. Available at: https://tenet.taleo.net/careersec tion/10100/jobdetail.ftl. Accessed May 7, 2012.
(10.) National Registry of Emergency Medical Technicians. What is EMS?. https://www.nremt.org/nremt/ about/What_is_EMS.asp. Accessed May 7, 2012.
(11.) Air& Surface TransportNursesAssociation. Staffing of Critical Care Transport Services. 2010. Available at:http://www.astna.org/documents/STAFFINGOF CRITICALCARETRANSPORTSERVICES_ 000.pdf. Accessed May 7, 2012
(12.) Wirtz MH, Cayten CG, Kohrs DA, Atwater R, Larsen EA. Paramedic versus nurse crews in the helicopter transport of trauma patients. Air Med J. 2002;21(1):17-21.
(13.) Hartenstein I. Medical evacuation in Afghanistan. Technical evaluation report summarizing the proceedings at the NATO specialist meeting 157, 2-3 December 2008, in Sieburg, Germany. North Atlantic Treaty Organization; 2009. Available at: ftp:// ftp.rta.nato.int//PubFullText/RTO/MP/RTO-MP HFM-157/. Accessed May 4, 2012.
MAJ Michael W. Wissemann, AN, USA
MAJ Christopher A. VanFosson, AN, USA
MAJ Wissemann is Chief Nurse, McAfee Army Health Clinic, White Sands Missile Range, New Mexico.
MAJ VanFosson is a Clinical Staff Nurse, Burn Intensive Care Unit, US Army Institute of Surgical Research, Fort Sam Houston, Texas.
* A nonrated member of a flight crew is an officer or enlisted Soldier who does not have the aeronautical rating of Army aviator or flight surgeon. (4)
* PROFIS predesignates qualified Active Duty health professionals serving in other units to fill Active Duty and early deploying and forward deployed units of Forces Command, Western Command, and the medical commands outside of the continental United States upon mobilization or upon the execution of a contingency operation.
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|Author:||Wissemann, Michael W.; VanFosson, Christopher A.|
|Publication:||U.S. Army Medical Department Journal|
|Date:||Oct 1, 2012|
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