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An Illustrious History
The concept of moving the wounded by air began almost simultaneously with the concept of fixed-wing aircraft flight.1 Shortly after the Wright brothers successfully flew their first airplane, two US Army medical officers, Capt George H. R. Gosman and Lt A. L. Rhodes, designed an airplane to transport patients. Using their own money, they built and flew the world’s first air ambulance at Fort Barrancas, Florida, in 1910. Unfortunately, on its first test flight, it flew only 500 yards at an altitude of 100 feet before crashing. This flight, followed by Captain Gosman’s unsuccessful attempt to obtain official backing for the project, proved to be only the beginning of many challenges for the new concept.
World War I Era
Air evacuation was very limited during World War I; however, it was remembered most as the time during which air-ambulance design made significant progress by trial and error. A French medical officer, Dr. Eugene Chassaing, first adapted French military planes for use as air ambulances by inserting two patients side by side into the fuselage behind the pilot’s cockpit. The first actual evacuation of wounded in airplanes specifically equipped for patient movement occurred in Flanders in April 1918, using a modified Dorand II aircraft.
The United States began to use airplanes for evacuating the injured from the battlefield in World War I but found it difficult to use planes not designed for patient airlift. Specifically, the fuselages were too small to accommodate stretchers, and the open cockpits exposed patients to the elements. As a result, the US Army Medical Corps used airplanes primarily to transport flight surgeons to the site of airplane accidents to assist in the ground transportation of casualties.
By war’s end, the US Army realized the need to transport the wounded by air. In 1918 Maj Nelson E. Driver and Capt William C. Ocker converted a Curtiss JN-4 Jenny biplane into an airplane ambulance by modifying the rear cockpit to accommodate a standard Army stretcher carrying an injured person in a semireclined seat. The modification allowed the US Army to transport patients by airplane for the first time. This success led to an order directing all military airfields to have an air ambulance.
Between the World Wars
The success of the Jenny air ambulances during World War I paved the way for the further development of air evacuation, with several other types of aircraft converted successfully for this purpose. In 1920 the DeHavilland DH-4 aircraft modification allowed it to carry a medical attendant and two side-by-side patients in the fuselage. Shortly thereafter, the Cox-Klemmin aircraft became the first plane built specifically as an air ambulance, carrying two patients and a medical attendant enclosed within the fuselage. The building of the Curtiss Eagle in 1921 allowed the transport of four patients on litters and six ambulatory patients. Unfortunately, in its first year of service, an Eagle crashed during an electrical storm, killing seven people.
Despite the crash setback, aeromedical transportation continued to progress. In 1922 the US Army converted the largest single-engine airplane built at the time, the Fokker F-IV, into an air ambulance designated the A-2. In the same year, a US Army physician, Col Albert E. Truby, listed the potential uses of the airplane ambulances as follows:
• Transportation of medical officers to the site of crashes and evacuation of casualties from the crash back to hospitals.
• Transportation of patients from isolated stations to larger hospitals, where they could receive better treatment.
• In time of war, transportation of the seriously wounded from the front to hospitals in the rear.
• Transportation of medical supplies in emergencies.
Before long, others began to recognize the need for air transportation of patients and the special training that would be required for medical attendants. Mary Beard, registered nurse (RN) and director of the American Red Cross Nursing Service in 1930, stated, “No one of our nursing organizations, no leading school of nursing, nor any other professional group, has taken up this subject seriously and definitely tried to promote the organization of a group of nurses who understand conditions surrounding patients when they are traveling by air.” After a 15-year crusade, visionary Lauretta M. Schimmoler, RN, succeeded in establishing the Aerial Nurse Corps of America.
World War II
At the beginning of World War II, the common belief was that air evacuation of the sick and wounded was dangerous, medically unsound, and militarily impossible. The Army Medical Department did not believe that the airplane was a substitute for field ambulances, even when it was necessary to evacuate casualties over long distances. The surgeon for the Army Air Forces (AAF) Combat Command, Maj I. B. March, was concerned that field ambulances would not be sufficient to cover the aerial paths of the air forces. In response, the surgeon general of Third Air Force, Lt Col Malcolm C. Grow, stated that the “chief stumbling block in the way of [air] ambulances has been the lack of interest on the part of the [Army] Surgeon General. Until he accepts the airplane as a vehicle [for casualty transportation], I doubt if very much can be done about it.”
The war soon demonstrated the necessity of air evacuation. The Burma Hump airlift operation saw what was probably the first use of helicopters for combat rescue, often the first step in the air-evacuation process. In one instance, TSgt Ed Hladovcak of the 1st Air Commandos, piloting an L-1 with three wounded British passengers, was forced down over 100 miles behind Japanese lines. Deep in the jungle where an airplane could not land, unable to move because of the injured Brits, and ground-rescue forces days away, the downed men hid from nearby enemy soldiers. The only option was to dispatch a YR-4 helicopter with its 175-horsepower engine to try a rescue. The YR-4 could carry only one passenger at a time, straining its engine past the redline just to lift off. Despite these difficulties, four trips were made in and out to a sandbar, where the men could safely transfer to an L-5. The mission was a great success. Successful combat rescues and air evacuations were to continue throughout the Hump operation.
The need to transport large numbers of casualties back from distant theaters of war was apparent, but designated air-evacuation aircraft did not exist. AAF policy was to use transport planes for air-evacuation flights as their secondary mission. Transport aircraft were reconfigured for air evacuation, using removable litter supports. In this way, aircraft that transported men and supplies to the theaters of operation were utilized as air-evacuation aircraft on their return trip. By January 1942, AAF C-47 Skytrain aircraft had transported more than 10,000 casualties from Burma, New Guinea, and Guadalcanal.
As air evacuation evolved, it became clear that specially trained personnel were needed to optimize casualty care during air transport. Because there were not enough physicians to put on every flight, Brig Gen David Grant, AAF air surgeon, proposed establishing a flight-nurse corps. Despite opposition from the Army surgeon general, the designation “flight nurse” was created for specially trained members of the Army Nurse Corps assigned to the AAF Evacuation Service. In February 1943, the first class of flight nurses graduated from Bowman Field, Kentucky. The four-week course taught aeromedical physiology, aircraft-loading procedures, and survival skills. This specialized training was the beginning of trained medical personnel providing in-flight care—the catalyst for the current AE system.
Before long, regular AE routes were established, and hospitals were built along airstrips to care for the wounded who needed to remain overnight along the route. In early 1943, AE aircraft began transatlantic flights from Prestwick, Scotland, to the United States. By the end of the same year, transpacific AE flights were returning patients to the continental United States (CONUS) via Hawaii. In 1944 a southern Atlantic route to the United States, originating in North Africa with stopovers in the Azores and Bermuda, began serving passengers. Aircraft used for AE during the war included the C-46 Commando, C-54 Skymaster, C-64 Norseman, C-87 Liberator Express, and the aforementioned C-47. In addition, bombers and tankers moved patients from forward battle zones during tactical AE.
The sheer number of patients transported during World War II reflects the great importance of AE. At its peak, the AAF evacuated the sick and wounded at a rate of almost 100,000 per month. A one-day record of 4,704 AE patients evacuated was set in 1945. In his statement on 18 June 1945, Gen of the Army Dwight D. Eisenhower said, “We evacuated almost every one of our forward hospitals by air, and it has unquestionably saved hundreds of lives—thousands of lives.” General Eisenhower placed AE in a class with sulfa drugs, penicillin, blood plasma, and whole blood as a chief factor in cutting the fatality rate of battle casualties.
The risk of evacuating patients by air had been a concern since the beginning of the war. However, as AE crews gained experience, the risk of death during AE dropped to six patients in 100,000 by 1943. At the end of the war, the risk was down to one and one-half patients in 100,000, thus proving that AE was one of the most important medical advances in decreasing the mortality rate associated with warfare.
Postwar Period and a New Service
The postwar drawdown changed the face of the US military’s AE system. By 1946 the system consisted of 12 aircraft at the School of Aviation Medicine and one C-47 at each of the 12 regional US hospitals. In 1947 the US Air Force (USAF) was established, receiving orders in 1949 to provide AE for the entire US military.
In May 1949, the Joint Chiefs of Staff (JCS) directed the Air Force to establish “evacuation systems” for both the Army and Air Force. On 7 September 1947, Secretary of Defense Louis E. Johnson made a policy announcement directing that the transportation of patients of the armed services would be accomplished by aircraft when air transportation was available, when conditions were suitable for air evacuation, and when there was no medical contraindication to air transport.
The Military Air Transport Service (MATS) had researched aircraft development in the AE role before its formal organization. The C-47 and C-54 were the mainstays of early CONUS AE. MATS provided regularly scheduled AE missions and transported 12,369 patients within the CONUS from June through December 1948. During this same period, 5,151 patients were moved from locations outside the continental United States (OCONUS) (i.e., overseas) to the CONUS. Intertheater AE from Europe began on 11 October 1949, with the C-121 Constellation (Connie). The C-121 provided a higher ser-vice ceiling, pressurized cabin, and smoother transatlantic crossings than the C-54. Eventually, the C-121 replaced the C-54 on the twice-weekly “Benefactor” AE missions from Rhein-Main, Germany, to Westover Air Force Base (AFB) Massachusetts. During this same period, C-54 aircraft serviced the Pacific theater. On 1 June 1950, the new MATS C-97A Strato-freighter was introduced into the AE role. With its larger carrying capacity and pressurized cabin, the weekly C-97A flight replaced the four trips per week flown by the C-54.
The Korean War
Whereas World War II had proved the value of AE, the Korean War established it as the preferred method of evacuation for US casualties. Although bad weather, mountains, and enemy fire hampered AE in the Korean War, Air Force rescue helicopters (C-47/C-54) still managed to evacuate most of the war’s casualties.
Air Force H-5 rescue helicopters of the 3d Air Rescue Squadron went into action as frontline medical craft. C-47 transports of the 315th Air Division, carrying AE crews, flew into the most forward airstrips under enemy fire, saving thousands of American lives. The Air Force’s 801st Medical Air Evacuation Squadron (one of the first units to receive a distinguished unit citation) evacuated more than 4,700 casualties from the Chosin Reservoir in December 1950. This aeromedical support enabled the embattled 1st Marine Division to execute a successful fighting withdrawal to the port of Hungnam on the northeast coast of Korea. The Army soon set up its own helicopter-evacuation service and, by late 1951, combined AE support to enable naval ships in-theater to serve as floating hospitals rather than simply transports for the wounded. Most American patients were airlifted to Japan, Hawaii, and the United States.
MATS used C-46, C-47, C-54, and C-124 aircraft to transport 137,950 patients between stations overseas and from OCONUS to the CONUS during the Korean War. Additionally, MATS provided for the movement of 215,402 patients within the CONUS. In a restatement of the USAF mission in 1953, MATS was charged with “the provision of airlift for patients of the Department of Defense on overseas routes over which MATS operates, from ports of debarkation, and between air facilities serving hospitals within the zone of interior.” AE was now a major mission of MATS—no longer a corollary task limited to the forward delivery of cargo or passengers.
Specialized Aircraft for AE
The next major AE development was the introduction of the Convair C-131A Samaritan. This pressurized aircraft, with a specialized interior for AE, offered fast service for the short air routes of Europe and North Africa. The C-131A, which made its debut on 26 March 1954, had a cruising speed of 235 knots; it had room for 37 ambulatory patients or 27 litter patients plus four ambulatory patients, as well as a medical crew of three. The aircraft configuration accommodated specialized medical equipment such as an iron lung, orthopedic bed, artificial kidney machine, or infant incubator. All Samaritans were distinctly marked with a red cross on the tail.
In June 1966, Headquarters USAF directed Air Force Systems Command to submit a proposed source-selection and procurement plan for a new AE aircraft. In July 1966, the Department of Defense agreed to initiate a modernization program, and in January 1967 it approved the expenditure of $34 million to purchase eight aircraft plus spares. Three contractors responded with proposals: McDonnell-Douglas (DC-9A), British Aircraft Corporation (BAC-111), and Boeing (B-737). On 31 August 1967, McDonnell-Douglas received the contract, with the first aircraft delivery scheduled for August 1968, followed by one per month for seven months. The rollout ceremony of the C-9A Nightingale occurred on 17 June 1968. The aircraft was tested and delivered to Scott AFB, Illinois, on 10 August 1968. Eventually, 21 C-9As were purchased between 1967 and 1971.
The Vietnam War
Advances in AE improved medical care during the Vietnam War. Rapid evacuation of the wounded from Vietnam’s battlefields by helicopters, followed by jet transports, saved many lives. Pacific Air Forces (PACAF) operated in-country aeromedical service and transoceanic jet service to hospitals at Clark Air Base (AB), Philippines, as well as Yokota AB and Tachikawa AB, Japan. Military Airlift Command (MAC)—the successor to MATS—helped evacuate many casualties from Vietnam, handling all patient movement to the United States. Although the Air Force acquired its first C-9A in August 1968, C-9As did not begin flying missions in Southeast Asia until March 1972. Ordinary transport planes— primarily the C-7 Caribou, C-130 Hercules, and C-141 Starlifter—equipped with litters flew most of the war’s aeromedical missions. PACAF’s 903d Aeromedical Evacuation Squad- ron provided the first mobile casualty-staging facility during this war.
Subsequent to Vietnam, AE supported a variety of contingency and humanitarian operations over the next two decades. The more notable ones included Operation Homecoming—the return of US prisoners of war from Vietnam; return of the 52 American hostages held in Iran for over 400 days; evacuation of casualties from the bombing of the US Embassy and Marine Corps barracks in Beirut; and evacuation of 167 casualties from Grenada. Officially designated mobile aeromedical staging facilities (MASF) were in the AE inventory and available when Operation Urgent Fury in Grenada took place in October 1983 but were not used.
Operation Just Cause and the Gulf War
AE proved to be a key factor in the overall success of Operation Just Cause in December 1989. During that short but violent conflict to oust Panamanian dictator Manuel Noriega, wounded American soldiers, sailors, airmen, and marines received care at the joint casualty collection point (JCCP) at Howard AB, Panama. The JCCP, which included both conventional and special-operations assets, combined surgical and mobile aeromedical-staging capability into one element by employing MASFs for the first time. The JCCP treated 276 patients, stabilizing and evacuating 257 to military hospitals in San Antonio, Texas, on nine AE missions (using eight C-141s and one C-130). Four of the nine missions (which evacuated 192 casualties) took place during the extremely intense first 24 hours of the operation. The overall survivability rate for American service members treated at the JCCP during the operation was 99.3 percent (276 total casualties treated; only two died from their wounds). Furthermore, no deaths occurred during AE missions.
The next challenge for AE came in response to Iraq’s invasion of Kuwait in August 1990. During the weeks preceding the start of Operation Desert Storm, United States Central Command predicted that as many as 15,000 Americans would be wounded in the early stages of the allied invasion to reclaim Kuwait. With the help of aeromedical elements from the Air Force and medical units from the Army, Navy, and Air Force, a coordinated, multitheater chain of evacuation was created to evacuate potential casualties. The Air Force AE system, totaling over 1,950 personnel, included 19 AE liaison teams, 12 MASFs, 99 tactical AE crews, 46 strategic AE crews, and 22 flight surgeons, as well as a number of C2 and support elements. The plan was to use medically configured C-130s for dedicated evacuation flights within the Persian Gulf, followed by a combination of dedicated and retrograde C-141s evacuating the most seriously wounded to Europe and the CONUS.
The mobilization and deployment of Air Reserve Component (ARC) forces were essential to the evacuation plan due to extremely high patient-movement planning factors—up to 6,000 per day. ARC accounted for almost 97 percent of the total AE forces, serving in a multitude of AE elements that created an elaborate evacuation chain stretching from Southwest Asia to the CONUS. The planning factors for AE, predicated on a six-week rather than six-day air war were very high. Predictions averaged over 1,000 intratheater patient movements per day, and intertheater AE movements were predicted to average an additional 900 patients per day.
Most Air Force planners did not anticipate that the air and ground fighting during Desert Storm would hardly tax the medical system. Coalition casualties were so light that the staff at Air Force contingency hospitals in Europe, like many of their counterparts in the Arabian Peninsula, practiced very little combat medicine. From August 1990 to March 1991, disease and nonbattle injuries accounted for most of the patients evacuated from Southwest Asia to Europe during Desert Shield/Storm. An aggressive preventive-medicine campaign was implemented, proving very effective in minimizing losses to disease.
During Desert Shield/Storm, several significant issues arose to challenge the AE forces, including the lack of Kevlar protective equipment for many of the Guard/Reserve personnel; the need for contingency training for the ground AE elements as well as a more streamlined, coordinated process for patient regulating; and review of interface points with the AE system. Nonetheless, the mission involved the largest deployed AE force in history, totaling over 12,632 patients evacuated on 671 AE flights with no in-flight deaths—a complete success.
Change in the Nineties
A new era in airpower history began on 1 June 1992 with the inactivation of MAC, Strategic Air Command, and Tactical Air Command. Two new organizations—Air Combat Command (ACC) and AMC—developed from the elements of the deactivated commands. Shortly afterward, AMC divested itself of infrastructure and forces not directly related to Global Reach. Among the units affected were C-130 airlift squadrons and AE squadrons at Rhein-Main AB, Germany, which transferred to United States Air Forces in Europe (USAFE), and similar squadrons at Yokota AB, Japan, which transferred to PACAF. These transfers—along with the majority of active and ARC C-130 airlift squadrons; the active-duty AE squadron at Pope AFB, North Carolina; and the 19 gained AE squadrons from the ARC—all went to ACC in order to align all theater (combat) support under one command. However, in 1997 these same assets were transferred back to AMC.
In 1996 the Global Patient Movement Requirements Center (GPMRC) was established within US Transportation Command to facilitate and streamline patient validating and regulating. Theater Patient Movement Requirements Centers also stood up in US Euro-pean Command and US Pacific Command. These centers are responsible for definition and management of patient-movement requirements, patient in-transit visibility, and collaboration with their respective theater or joint-task-force movement-control agency to coordinate bed and lift plans.
Because of lessons learned in Desert Shield/Storm, an Aeromedical Evacuation Contingency Operations Training (AECOT) course was developed and fielded at Sheppard AFB, Texas, in September 1998. The course trains AE personnel in a standardized manner regarding general philosophy, capabilities, organization, operations, C2, and support required to provide full-spectrum AE capability during contingencies.
In 1999 a Critical Care Air Transport Team (CCATT) course was developed at Brooks AFB, Texas, to prepare teams of physicians, nurses, and technicians to provide structured en route care for critically ill and injured patients whenever and wherever required. The course includes a detailed review of the CCATT mission, equipment, and organization, as well as familiarization training with AE aircraft, orientation to the stresses of flight, and refresher training through a fundamental critical-care support course.
Throughout the nineties, AE units continued to be engaged in a variety of contingency operations covering multiple theaters. AMC and AMC-gained units deployed 60 medical personnel for 90 days in the fall of 1994 to manage an air-transportable hospital in support of Operation Uphold Democracy. Those medical personnel were responsible for treating and aeromedically evacuating, if necessary, all military personnel deployed. In addition, Air Force medics deployed to austere locations throughout Haiti to take part in the humanitarian-assistance program.
Additionally, active duty and ARC AE forces joined to support operations in Kenya, Rwanda, Saudi Arabia, Kuwait, Bosnia, Somalia, and Kosovo. AE evacuated many critically injured Rangers and special operations forces to Ramstein AB, Germany, after the 3 October 1993 “Bloody Sunday” firefights in Moga-dishu, Somalia. AE personnel supported Operation Allied Force with crews and mobile aeromedical-staging facilities. Moreover, those same personnel concurrently supported Operation Shining Hope, a humanitarian cause. The first four AE missions flown out of Tirana, Albania, were on C-17 Globemaster IIIs, demonstrating the effective use of opportune airlift. In each operation, the presence of AE forces ensured the prompt and safe aeromedical evacuation of military personnel who needed more care than was available locally. Finally, throughout the nineties, AE units supported humanitarian civic-action operations in various locations throughout Central and South America. With the adoption of a new casualty-replacement policy and a smaller presence in overseas contingency theaters, AE became even more important as the twentieth century closed.
Time for Change
By the late nineties, AE faced new and daunting challenges. Modern conflict, routinely characterized by rapid, short-duration, high-intensity combat, has resulted in casualty generation with very little lead time. As a result, there is often no opportunity to set up en route contingency hospitals, and critically ill patients frequently have to be evacuated long distances to reach comprehensive medical care. This necessitates the movement of “stabilized” (rather than fully stable) patients, who often require intensive care during evacuation.
In December 1998, during an internal review of current AE posture, AMC identified a number of critical issues with significant potential to affect future AE operations. These included the Air Force’s evolution into the expeditionary aerospace force (EAF) concept and air expeditionary force (AEF) structure; implementation of TRICARE; evolving doctrine and command relationships; changing patient-movement requirements; the impending retirement of the core strategic AE aircraft, the C-141, which currently performs the majority of peacetime intertheater AE missions; and the status of the dedicated intratheater AE platform, the aging C-9A, which requires major modifications to meet both global air traffic management and stage III noise-compliance requirements. As evidenced by the above, today’s AE system is designed for a world that no longer exists. Today’s changing environment demands a new look.
In August 1999, Lt Gen Walter S. Hogle Jr., AMC vice commander, directed a review of the entire AE mission area and established an integrated product team chaired by AMC Plans/Programs (XP) with the support of the AMC command surgeon. In September 1999, a multicommand AE Tiger Team (AETT) was formed to address the following areas: requirements, doctrine, operations, airframes, organization, resourcing, equipment, communications, information management/information technology, education, training, and awareness. This team generated a comprehensive final report—the road map to implement recommendations.
Major Findings and Key Recommendations
Requirements. Wartime casualty projections, including an added 25 percent to account for weapons of mass destruction, were 30–55 percent lower than in 1996.2 Peacetime patient movement was greatly reduced in the CONUS due to TRICARE, but OCONUS requirements remained fairly constant because TRICARE was not as robust and quality-of-life issues mandated the need for AE.
Doctrine, Operations, and C2. Recommendations included the following:
• Insert an AE control team in the air mobility division (AMD) with coequal status to the existing airlift, air refueling, and air mobility control teams.
• Align the patient-movement requirement centers under the appropriate mobility control centers at the unified commands.
• Formally establish AE cells in the air mobility control centers of the component air commands (Tanker Airlift Control Center in AMC and Air Mobility Operations Control Centers in USAFE and PACAF).
• Clarify the chain of command for fielded AE forces, with AE as a line/operations function under the joint force air component commander (JFACC) through the deployed mobility wing commander and the operations group commander.
• Change AE processes to a requirements-based system and optimize the use of limited airframes. Mix patients and cargo when appropriate; gain visibility, using routine training missions for live missions; and use space required/space available, opportune airlift, or commercial air service.
Airframes. The major recommendations included the following:
• Option One—Pursue a strategic-distance aircraft dedicated to AE.
• Option Two—If the short-term financial constraints (acquisition costs) of such a purchase preclude option one, turn both the peacetime and wartime intratheater AE missions over to the C-130 fleet in a designated role, which would require a slight increase of C-130s in each theater.
• Investigate the concept of modifying KC-135s as an immediate, short-term intertheater fix for the retiring C-141s. This would require AMC funding for electrical modifications to a small number of KC-135s for testing and follow-on funding for additional KC-135s, based on test results. Pursue funds for a roll-on/roll-off litter capability.
Since publication of AETT’s report, factors such as fiscal limitations, aircraft tasking and availability, and changing national strategy have prompted a relook at all aircraft recommendations. Further, analysis is ongoing to determine whether a shortfall of organic AE aircraft exists. Another focus is on mainstreaming AE into airlift operations and enhancing operations with the use of seats, pallet spaces, and palletized system concepts.
Organization. The team had begun to reengineer and incrementalize existing AE flying and ground-support unit type codes (UTC) in order to eliminate the need to routinely pare and tailor them to meet operational requirements. For example, the existing 50-bed MASF (which includes 39 personnel and requires seven C-130s to move it) was reengineered and incrementalized. The new MASF consists of a 10-bed basic package that can be augmented with additional 20-bed packages, as needed. This building-block approach provides significantly enhanced mission flexibility and reduces airlift requirements from seven to three C-130s. Another proposal was to form “virtual combination units,” which would allow geographically separated units the opportunity to work, train, deploy, and fight together, thereby improving integration and meeting ongoing Air Force Total Force efforts for the future.
Resourcing. The team reinforced the concept that the Defense Health Program (DHP), operated and funded by the Office of the Secretary of Defense/Health Affairs, was responsible for all means of peacetime patient movement. However, Air Force aircraft may accomplish some patient movement by using training missions funded by operations and maintenance (O&M). The program budget decision transferred all funding for active duty C-9A and AE squadron operations from DHP to Air Force O&M on 1 October 2000. The team recommended decentralizing DHP funds to each theater to provide flexibility for patient-movement options. This funding would allow the purchasing of seats or pallet spaces on existing cargo missions, AE channel missions (if required), and civilian air ambulance or commercial airlines (when appropriate).
Equipment, Communications, and Information Management/Information Technology (IM/IT). Recommendations included the following:
• Fund the deployable oxygen-system initiative.
• Exercise Care in the Air (CiA), airborne wideband, and other AE communication and IM/IT initiatives during the joint expeditionary force experiment (JEFX) 2000.
• Finalize a stopgap communication plan to meet fiscal year 2002 joint requirements.
• Complete redistribution of high-frequency communications assets.
• Continue integrating and maintaining computer-based training for the Spitfire (PSC-5) radio.
• Continue pursuing the joint tactical radio system.
• Publish the AE communication concept of operations on the Air Force surgeon general (SG) Web page.
• Update and incrementalize AE communications allowance standards.
Education, Training, and Awareness. Recommendations included the following:
• Create an “Aeromedical Evacuation Center of Excellence” as a one-stop shop for AE education and training.
• Develop a flight-qualification program to standardize initial qualification for AE crew members.
• Train “universal” crew members, eliminating the “tactical/strategic and multiqualified crew” paradigm in use today. Specially qualified AE crew members will be certified in multiple airframes to provide CiA.
Gen Charles T. Robertson Jr., AMC commander, approved the AETT report on 26 September 2000, and Gen Michael E. Ryan, then the Air Force chief of staff, lauded the effort: “Please pass on to your XP and SG folks that they have done a yeoman’s job on AE reengineering. General Carlton and I are impressed with the incrementalization/revamping of AE assets to better match the AEF and the Air Force medical system’s direction of smaller, leaner, and more capable deployment units.”3
Accomplishments to Date
By the end of 2000, the AETT had accumulated an impressive list of accomplishments, beginning with the determination of peacetime and wartime AE requirements. In peacetime, with the changeover to TRICARE medical coverage, the need to move patients had declined in the CONUS from approximately 69,700 patient movements in 1995 to 19,500 movements in 1999, with only 1 percent classified as priority or urgent. As mentioned earlier, in the overseas theaters, because of TRICARE’s lack of robustness and because of quality-of-life issues, the requirements remained steady. This was also due to the significant closing of OCONUS medical facilities after the Cold War, requiring the movement of patients to CONUS facilities. With regard to wartime requirements, the overall wartime casualty projections were 30–55 per-cent less than the projections made in 1996. The projections were based on changes in war-fighting concepts, evacuation policies, theater medical capabilities, and the smaller numbers of soldiers at risk.4
One recommendation, to insert an AE control team into the Air Operations Center, was approved and articulated in Air Force Doctrine Document (AFDD) 2, Organization and Employment of Aerospace Power, February 2000. In addition, a decision brief presented in January 2001 defined the roles and respon-sibilities of the unified/component command. Also, the Tanker Airlift Control Center (TACC) and GPMRC finalized a memorandum of agreement that addressed communication flow and responsibilities. The AE “Tactics, Techniques, and Procedures” was published through the Doctrine Center in June 2001, followed by approval of the AE Doctrine Template by the AMC commander in July 2001. The use of the approved template in updating various joint and allied publications resolved long-standing joint and service doctrinal issues.
Another key factor in aligning the AE organizational structure took effect 1 October 2000, when the TACC stood up an AE cell designated TACC/XOGA. Major benefits in scheduling, improved response time, and decreased cost were realized almost immediately as the cell implemented various recommendations. The cell began working mixed cargo and AE missions on Atlantic Express C-17s and used air-refueling missions, when appropriate, as well as Patriot Express passenger missions for patient movement. These mixed missions resulted in an overall increase in AE mission reliability. C-141 AE missions continued to be scheduled, but their reliability remained an issue. In the Pacific, mixed missions continued using C-17s and KC-135s while exploring other options. For example, an August 2000 mission involved a C-17 reconfigured after a repatriation mission from Pyongyang, Korea, in an urgent attempt to save a five-day-old baby girl. The AE crew, made up of active duty and Reserve personnel, flew the 14-hour return leg from Yokota AB, Japan, to the United States, refueling in-flight from a KC-10 Extender, which was also carrying an urgent-care patient. In another example, a C-17 cargo mission moved a litter patient from the Pacific to the CONUS. In the past, this would have resulted in the initiation of an AE channel mission costing approximately $81,000. In this case, purchasing space for a cost of $1,415 resulted in a savings of $79,585. These are just two examples of the benefits of TACC and AE cell interface and their efforts to embrace the changing AE process and to continue working with the theaters to meet their patient-movement needs.5
The vision represents a shift from the way we do business today and calls for the military community to refocus its view of AE from what was suitable in the past to what is necessary for the future.
Other efforts under way include transitioning AE personnel and functions from AMC/SG to AMC/director of operations (DO) and AMC/XP, reengineering the aeromedical staging facilities, integrating CCATTs, funding war-reserve material, defining a homeland defense mission, and sponsoring a regional Total Force virtual-group pilot study.
A New Vision for AE
In addition to the AETT final report, several other factors—maturing TRICARE regionalization, the imminent C-141 and C-9A retirements, recently validated planning factors increasing the wartime casualty stream by 25 percent, fiscal realities of AE modernization competing with other Air Force modernization programs, and recognition of the inevi-table continuing evolution of AE—prompted AMC to redefine basic AE constructs. Brig Gen Jim Roudebush, AMC surgeon, drafted a concept known as “A Vision for Aeromedical Evacuation: Supporting Global Reach, Vigilance and Power into the New Millennium,” November 2000, which outlined several precepts for AE in the future.6 The vision represents a shift from the way we do business today and calls for the military community to refocus its view of AE from what was suitable in the past to what is necessary for the future.
The military has evolved from a strategy of containment to a strategy of engagement. We have moved from a monolithic threat environment with a heavily forward medical infrastructure to the present environment characterized by complex asymmetric threats, a light forward medical presence, and a heavy reliance on AE to transport more critically ill and injured forces and their families.
In May 2001, this vision evolved further during preparation for a briefing at CORONA.7 The AE system is now in a period of transition from an “outlier” process with separate funding, scheduling, and flying to “mainstreaming” into operational airlift processes. The vision incorporated the AETT analysis and road map and includes the following key precepts necessary to mainstream and modernize AE:
• View AE as a specific medical-airlift mission capable of supporting patients on any appropriate airlift platform.
• Adapt AE to fully capitalize on the use of current organic-lift platforms.
• Develop light, modularized, and independently operable AE equipment.
• Design an adaptable, multiairframe-capable, palletized litter/seat system.
• Capitalize on contract lift opportunities—Patriot Express, commercial airlines, and civilian air ambulance—where the use of these modalities is appropriate and cost-effective.
• Establish AE qualification training designed to support AE on all appropriate platforms.
• Address the critical interface between the aircraft crew and the AE crew.
• Focus on two fundamental concepts: a crew is a crew and CiA.
• Develop a universal checklist that AE crew members could use on any AE-capable airframe.
• Acknowledge the continued requirement for mobilization of the AE Civil Reserve Air Fleet (CRAF) in wartime.
• Design AE capability into all appropriate future airframes.
• For example, multirole mobility platforms, KC-X (the future tanker and replacement for the KC-135) mission needs statement (MNS), and C-130J/ X upgrades.
• Recognize that as the C-9A and C-141 retire; as AE is assimilated into organic lift, to the extent possible; and as contract-lift modalities are utilized, . . . analysis indicates a residual shortfall in AE lift to meet echelons three and four wartime requirements.
• The AE MNS identifies AE integral requirements for future mobility airframes and addresses that shortfall between the AE wartime requirement and available lift in the most demanding scenarios.
The strategy for AE of the future was vetted by key stakeholders, including commanders in chief (CINC), Air Staff, major commands, and the Reserve/Guard. Their feedback included many positive and supportive comments, the major concerns centering on assuring availability of lift for the AE mission and training AE crew members for the flexible use of the organic-lift platforms. AMC leadership is committed and fully engaged to support the following:
• Assuring space in the airlift flow for AE requirements.
• Adapting AE to all appropriate airframes.
• Aggressively pursuing the full spectrum of airlift options for AE.
• Standardizing and enhancing training requirements.
• Planning and programming to assure that the AE mission is fully supported.
Consistent with this new vision, as the C-9A nears the end of its distinguished role in the Air Force, it will continue its service in a designated versus dedicated capacity. In February 2001, the Air Force chief of staff directed the removal of the red cross markings from the C-9A AE fleet.8 The C-9A will continue to be a primary AE asset; however, the new decision will permit flexible use of the aircraft in transporting duty and space-available passengers, as well as nonmedical supplies and equipment—without risking violation of domestic or international law. In concert with the decision, AMC/Logistics (LG) designed and acquired a nonpermanent, quick-application red cross for use during times of war, contingency operations, or other instances in which the display of the red cross would be both desirable and appropriate. This capability will allow the quick application of the red cross to any aircraft specifically dedicated for AE. This provides protection for patients, while allowing both AMC/TACC and theater air mobility operations control centers (AMOCC) additional flexibility in selecting from all available AE-capable aircraft for such missions.9 The reengineered AE system will focus on requirements-based scheduled support by purchasing seats and pallet spaces on the most appropriate aircraft rather than paying for entire airplanes. Government-contracted commercial augmentation use, complemented by scheduled routes based upon CINC-driven theater requirements, form the construct. Within the construct, a variety of aircraft will be available to support AE. Moreover, during contingencies, the staging of AE crew members and en route ground-support UTCs at any airhead where AE requirements may be generated, rather than tying them to specific aircraft bed-down locations, will allow increased flexibility.10
With the institutionalization of this new AE vision, changes to AE aircrew training and qualification become imperative. Unlike most crew members, AE crews will not be limited by qualification on specific airframes. The new vision will drive the need for a broad-based flight-qualification program, using simulators to train and qualify AE crew members on all potential airframes. In keeping with the flexible and expeditionary approach of the Line of the Air Force, AE will be a part of the mission portfolio of all appropriate aircraft, either integrally or by maximizing the use of portable AE equipment suited to all airframes. AE crews will be as flexible as the aircraft they use.
The new vision has taken the initial definitive step to ensure that the AE system is able to support the entire spectrum of AE requirements, from peacetime/steady-state to the full-scale casualty flow of two simultaneous major theater wars. The strategy of mainstreaming AE and employing the full spectrum of lift to support the AE mission will assure that AE will be capable of supporting our war-fighting expeditionary forces in peacetime and war. AE will be here for our forces and families, now and in the future.
Notes
1. This section draws upon Anything, Anywhere, Anytime: An Illustrated History of the Military Airlift Command, 1941–1991 (Scott AFB, Ill.: Headquarters Military Airlift Command, Command Historical Office, May 1991).
2. This section draws upon “Aeromedical Evacuation Tiger Team Final Report” (U), AMC/Medical Readiness and Aeromedical Evacuation Division (SGX) and AMC/Plans and Programs Studies and Analysis Flight (XPY), September 2000.
3. Message, 181630Z Jul 00, Air Force chief of staff (CSAF), to AMC commander, 18 July 2000.
4. Briefing, Col Sheila A. W. Millette, AMC/SGX, subject: Aeromedical Evacuation (AE) 2000: Supporting Our Expeditionary Forces, 15 November 2000, in “Aeromedical Evacuation Tiger Team Final Report,” September 2000.
5. Background paper, subject: Aeromedical Evacuation Tiger Team, AMC/XPY, 25 October 2000; briefing, AE 2000: Supporting Our Expeditionary Forces; and plan, subject: Air Mobility Command Concept of Operations for Aeromedical Evacuation, AMC/SGX, Scott AFB, Ill., 14 July 2000, in “Aeromedical Evacuation Tiger Team Final Report,” September 2000.
6. Brig Gen James G. Roudebush, briefing, subject: A Vision for Aeromedical Evacuation: Supporting Global Reach, Vigilance, and Power into the New Millennium, November 2000.
7. Brig Gen James G. Roudebush, AMC, Scott AFB, Ill., talking paper, subject: Aeromedical Evacuation: Supporting Global Reach, Vigilance, and Power into the New Millennium, 21 May 2001.
8. “Emblem Removed on C-9 Aircraft,” Air Force News Service, February 2001, on-line, Internet, 30 October 2001, available from http://www.af.mil/news/Feb2001/n20010212_0204.shtml.
9. Col Sheila A. W. Millette, AMC, Scott AFB Ill., talking paper, subject: Red-Cross Marked Aircraft, April 2001.
10. For more information on the AE reengineering, integration, and modernization effort, see Air Mobility Command/SG, on-line, Internet, 30 October 2001, available from https://amc.scott.af.mil/sg/sg.cfm .
Contributor
Brig Gen Bruce Green (BS, University of Wisconsin; MD, Medical College of Wisconsin; MPH, Harvard University) is command surgeon, United States Transportation Command (USTRANSCOM) and Headquarters Air Mobility Command (AMC), Scott AFB, Illinois. He is a director on the staff of the commander in chief, United States Transportation Command. In this capacity, he ensures both the maximum wartime readiness and combat-support capability of worldwide patient movement, aeromedical evacuation, the Global Patient Movement Requirements Center, and AMC’s 12 community-based medical-treatment facilities. He leads more than 8,000 AMC medical personnel, providing care to more than 456,000 beneficiaries, and oversees an annual budget of $796 million. As the command surgeon of USTRANSCOM, he advocates the Department of Defense’s efforts to reengineer the Global Patient Movement System.
Disclaimer
The conclusions and opinions expressed in this document are those of the author cultivated in the freedom of expression, academic environment of Air University. They do not reflect the official position of the U.S. Government, Department of Defense, the United States Air Force or the Air University.
contains info from Air University
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